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West Virginia University Libraries 

3 0802 

02296109 4 



Dr. F. M. Farnsworth 

Buckhannon , _W^_Va^_ 






E. P. R. RYAN 









Copyright, 1914, by P. Blakiston's Son & Co. 











This book has been designed for medical and dental 
practitioners and students, for nurses; and especially 
for hospital corps men of the military and naval service 
and for all who are called upon to administer relief from 
dental pain, where the services of a dental surgeon cannot 
be obtained. 

The impulse prompting this book was not to multiply 
books, but arose from the writer's belief and that ex- 
pressed by many practitioners, both medical and dental, 
that this hand-book is needed by those it is intended to 

The extent and scope of the methods described are 
limited to First Aid, which will relieve the patient from 
suffering until a dental surgeon may complete the treat- 
ment. A minimum number of instruments is recom- 
mended and their use shown and described. 

The methods used are simple and the descriptions have 
been written in the simplest words, technical terms 
being eliminated as much as possible; all methods used 
can be accomplished on board ship or in the field or in 
any hospital or medical office. 

Due credit is given the works of modern writers, which 
have been consulted and without them it would have been 
impossible to accomplish what has been done. 

The gratitude of the writer is here expressed to Captain 
J. R. Harris, M. C, U. S. Army, for valuable suggestions 
and assistance; and special credit is due Mr. H. A. Utter 
for photos from which these illustrations were made. 

The Author. 


Chapter Page 

I. Septic Conditions of the Mouth i 

II. Salivary Deposits 6 

III. Inflammation of the Mucous Membrane of the Mouth . 16 

Stomatitis 16 

Herpes Labialis 17 

Canker " Sore Mouth" 18 

Injuries to the Membrane 19 

Smokers' Sore Mouth 20 

Marginal Gingivitis 21 

IV. Syphilis in the Mouth 25 

Primary 26 

Secondary . * 27 

Tertiary 29 

Differential Diagnosis 30 

Ptyalism (Salivation) 31 

V. Brief Dental Anatomy 34 

Deciduous Teeth 35 

Permanent Teeth 36 

Structure of Teeth 37 

Enamel — Cementum — Dental Pulp — Gums — Den- 
tine — Pericementum — Alveolar Process ...... 37 

VI. Dental Pain 42 

Inflammation of the Pulp 42 

Putrescent Pulp 44 

Pericementitis 46 

Non-septic 46 

Acute Septic — Acute Dento-alveolar Abscesses . . 46 

Chronic Dento-alveolar Abscesses 49 

VII. The Treatment of Pulpitis 52 

VIII. The Treatment of Putrescent Pulp and Non-septic 

Pericementitis 61 

IX. The Treatment of Abscesses 65 

Acute Dento-alveolar 65 

Chronic Dento-alveolar 67 



X. Neuralgia 72 

Treatment: Local and General 75 

XI. Pyorrhea Alveolaris 78 

Treatment and Instrumentation 84 

XII. Fractures and Dislocations of the Jaws and Their 

Treatment 88 

XIII. Dental Extractions 104 

Instrumentation \ . . 104 

Lancing 107 

Improvised Dental Chair 130 

XIV. Post-operative Conditions 134 

Pain after Extractions 134 

Hemorrhage after Extractions 135 

Fainting 137 

XV. Diseases of the Maxillary Sinus — Antrum of Highmore 

Operations and Treatment 138 

Authors, and Books Consulted 147 

Index ■ . 149 



The writer does not intend to go out of his sphere and 
make suggestions as to the treatment and diagnosis of 
disease in general, but merely to present some ideas 
from a dental standpoint which, in their connection with 
systemic conditions, are frequently overlooked. 

In the present-day importance of opsonia and vaccine 
therapy and the treatment of diseased conditions by these 
methods, greater emphasis should be placed on the con- 
dition of the mouth, with regard to the presence of patho- 
genic bacteria. The oral cavity is an ideal location for 
the cultivation of bacteria. Nutrient material is abun- 
dant, as well as a proper temperature and in most mouths, 

Consider a mouth containing many necrosed roots, at 
times floating in pus; teeth covered by tartar, crowding 
the tissue and preserving undisturbed shelves under the 
margins of the gums, for retention of decomposing food 
matter; cavities full of foul germ-laden substance; ill- 
fitting crowns, plates and fillings. It is hard to imagine 
more favorable conditions than these for the growth of. 
disease-producing germs. 

Miller 1 found upward of one hundred organisms in the 
mouth, thirteen varieties being common, with the follow- 
ing pus-producing organisms: 

1 " Micro-organisms of the Human Mouth/' Miller. 



Staphylococcus pyogenes aureus 34.8% of cases. 

Streptococcus. pyogenes 23 . 2% of cases. 

Staphylococcus pyogenes albus 18.6% of cases. 

Bacillus pyocyaneus 9 . 3 % of cases. 

Staphylococcus pyogenes citrus 4.6% of cases. 

The other eight varieties being harmless and varying in 
frequency. The fact that the staphylococcus and strep- 
tococcus organisms, the most active of pathogenic germs, 
are present to this enormous extent, should impress upon 
us the importance of the mouth as an etiological factor in 

The presence of these organisms is not to be considered 
merely as a cause of inflammation, stomatitis, gingivitis 
and local effects, which are seen; but it must be further 
considered that the mucous membrane of the rest of the 
alimentary tract has probably less power of resistance 
than the mouth. The wonderful resisting power which the 
mucosa of the oral cavity exerts and its ability to rebuild 
after injury is known to all, but this power is exerted only 
to resist for itself and to throw off, not to destroy or render 
less infectious, the cultures we swallow continually. 

The presence of pyorrhea is not the only cause of many 
disease conditions which we trace, or should trace, to 
absorption of bacteria. In the absence of pyorrhea, other 
inflammatory conditions of equal importance may exist 
in the mouth. 

There are many varieties of infectious condition of the 
mucous membrane, which will be dealt with in the follow- 
ing chapters. Hunter 1 has stated that Tonsillitis is very 
frequently the result of mouth infection; and the probable 
cause is infected sockets, membranes and abscessed teeth, 
the drain of which continually passes over these glands. 

A mouth which abounds in tooth decay, stomatitis, 

1 " Oral Sepsis," Hunter. 


gingivitis and pyorrhea alveolaris is a perfect menstruum 
for the development of bacteria. It is reasonable to 
charge to this condition, otherwise diagnosed diseases, 
especially in so closely related organs as the tonsils. The 
importance of this is manifold, since many other diseases 
frequently result from infection of the tonsils and from 
pharyngitis; and other affections may follow where 
stomatitis or gingivitis exist. 

Allan, in " Vaccine Therapy and Opsonic Treat- 
ment," says in regard to the administration of vaccines 
by the mouth, that favorable results were obtained in 
staphylococcal, streptococcal, pneumococcal and tuber- 
cular infections. This point thus arises. If vaccine can 
be successfully administered through the mouth, what 
must be expected where pus, laden with bacteria, is con- 
tinually swallowed? 

Latham (quoted by Allen) advocates the administration 
of vaccines by the mouth, on an empty stomach. He 
considers the absorption to be almost perfect at certain 
times. We must expect some absorption if bacteria and 
their products are continually swallowed when there is 
little or no hydrochloric acid in the stomach. 

Hunter 1 attributes to mouth organisms; gastritis, 
septic fevers, profound septicaemia, anaemia, tonsillitis, 
and pharyngitis, to which must be added, via the tonsils, 
many cases of muscular and articular rheumatism. 
Aaron Burr 2 has laid out a plan to prevent ocular disease, 
by the remedy of this oral condition. Miller 3 points 
out various diseases, such as diphtheria, syphilis, pul- 
monary diseases and disorders of the digestive tract, 
resulting from presence of bacteria in the mouth. 

The dentist is prone to discharge the patient after in- 

1 "Oral Sepsis," Hunter. 

2 "Dental Cosmos," July, 1910. 

3 "Micro-organisms of the Human Mouth," Miller. 


serting beautiful fillings, crowns, plates and appliances for 
the improvement of mastication; and to overlook the 
pus-ridden sockets and necrosed roots; thus leaving a 
source of infection discharging as before. The skillful 
surgeon, who, in preparation for all operations on the 
stomach and intestinal tract, is punctilious with his scrub- 
bing and disinfection beyond the slightest point of criti- 
cism, would consider it almost criminal to close an opera- 
tion, knowing he had a drop of pus in the wound, yet 
many to-day, are paying no heed to the disinfection of the 
oral cavity prior to an operation. 

Miller and others have shown that the pathological 
organisms can be killed in the mouth by proper steriliza- 
tion, yet this is not sufficient, for this is only temporary 
asepsis and the treatment must be kept up a sufficient 
length of time. 

In diagnosing gastric disorders the absence of proper 
teeth for mastication has been taken into consideration as 
an afterthought, and it was considered as detrimental 
in the disease. Tooth destruction was considered a result 
of regurgitated ferments from the stomach. This, how- 
ever, is the crudest conception, these conditions should be 
considered as the cause and not the result of the gastric 

Treatment and Sterilizating 

As described in Chapter II, calcareous deposits should 
be removed, teeth cleaned and polished, all spaces be- 
ing cleaned by floss, rubbers, etc., roots extracted and 
the sockets which are flowing with pus should be sponged 
out with a solution of listerine, 5 per cent, phenol or 
Dobell's solution in hot water. The writer has had suc- 
cess in using tincture of iodine, placed on a pledget of 


cotton and forced to the bottom of these sockets, the 
cotton being removed at once and followed with proper 
syringing. Necrosed alveoli should be scraped and par- 
ticles removed. 

For painful sockets a pledget of cotton saturated with 
campho-phenique or tincture of calendula is used to 
good advantage; or a thin paste of orthoform and iodo- 
form, equal parts, made with campho-phenique may be 
used; the pledget being left in the socket for twelve hours. 
When the mouth has been treated in this way, if the edges 
of the gums around the teeth are very much inflamed, it 
is well to paint these raw surfaces with a 5 or 10 per cent, 
solution of resorcin, a saturated solution of tannic acid in 
tincture of iodine, or a good counter-irritant. Then in 
twenty-four hours it will be well to have the patient use the 
brush with a little powdered pumice once or twice, as di- 
rected in the following chapter, and continue the mouth 
wash, allowing plenty of time for the antiseptic action of 
the solution. 



When the patient comes for emergency treatment, it 
is because he has suffered. In many cases, this is the only 
reason why he seeks relief or treatment. Our first duty 
is to give him relief. The various conditions with their 
emergency treatment will be taken up by subjects in the 
succeeding chapters. The following chart shows the per- 
centage of men who were treated by the writer during a 
recent period, the ages ranging from 18 to 35 years, where 
salivary calculus was present in each case and who were 
asked the question : " Do you clean your teeth? " Having 
treated these men, the veracity of the small percentage 
who claim they clean their teeth, is doubted. 

Patients treated a b 




540 99 72 




Explanation. — Teeth cleaned 

a. Three times daily. 

b. Once a day. 

c. Once a month. 

d. Never cleaned. 

This percentage of patients who come for emergency 
treatment is met with in every day practice. 

When a patient presents himself with fetid breath, 
swollen, bleeding gums and large masses of deposits on the 
teeth, with no individual tooth aching, there is evident 
lack of care and the condition demands emergency treat- 
ment. There are two distinct kinds of deposits, or tartai 
(as it is sometimes called) on the teeth. The two mosi 



frequent locations for it are just behind and on the lower 
margins of the lower incisors, joining and impinging on the 
gums, and on the buccal or cheek side of the upper molars. 
This is caused by the proximity of the ducts of salivary 
glands, the sub-maxillary and sub-lingual for the lower 
incisors and the parotid glands for the molars. 

The deposition of tartar is not a normal condition, as it 
is seldom found in wild animals, or people like the Indians, 

Fig. i. — Salivary calculus on the right side of the mouth where teeth 
were all in place and occlusion would be normal, were calculus removed. 
Presented for pain on this side of the mouth. Result of neglect. 

who use their teeth with gross food, so it naturally follows 
that the kinds of food we use, lack of exercise of the organs, 
and lack of care, account largely for its presence. 

As stated above, there are two kinds of tartar, viz., 
serumal and salivary. Serumal, as the name implies, 
is deposited from the serum of the blood and is always 
originally located under the free margins of the gums, 


where the blood supply, coming^into contact with the 
tooth, deposits it. This is the form found in patches or 
small rings on the sides and necks of the teeth. Some 
writers believe it to be the most dangerous class, because 
it is very hard and irritating to the peridental membrane 
and is believed to play a large part in the etiology of 
pyorrhea alveolaris. 

Fig. 2. — Opposite side of same mouth, one tooth missing, absence of 
calculus because of use for mastication. 

Salivary calculus is, as the name implies, derived from 
saliva, the analysis of which is as follows (quoted from 
Tome's "Dental Surgery 77 ): 

Salivary Calculus 

Earthy phosphate 79 • ° 

Salivary mucus 12.5 

Ptyalin 1 . o 

Animal matter in hydrochloric acid 7.5 


Salivary deposits are found in great quantities in neg- 
lected mouths. The writer has removed masses which 
have completely covered a tooth, no opposite tooth occlud- 
ing. Not only is the deposit of tartar to be taken into 
consideration, but where there are large patches, under 
the margin and in the shelf formed by them and the gum 
will be found a veritable hot-bed of bacteria, and in all 
probability some formation of pus. If there is an inflam- 
mation and irritation of the alveolar process, this emer- 
gency demands your attention. The bacteriological 
aspect resulting from this condition, and the mouth in gen- 
eral, has been taken up in another chapter. 

It is the intention of the writer to make plain the treat- 
ment, the methods and the instrumentation for remov- 
ing deposits, which will relieve the immediate condition 

The proper removal of deposits is not a simple matter 
and to successfully clean away this irritating substance 
will test the skill of a good operator. The description of 
a simple method of relieving this condition, will, how- 
ever, be attempted. 

There are two principal plans of procedure for removal 
of deposits, the push cut and the draw cut methods. 1 
Only the draw cut method will be suggested in this chapter. 
The daily use of the push cut method renders the process 
easy, but the occasional use of this method is not advised. 
The draw cut method does not alarm the patient because 
he feels you are drawing the instrument away from the 
sensitive tissues. The scalers in Fig. 3 are photo- 
graphed from two views, showing the shape, form and 
cutting edges. These four instruments will, if diligently 
applied, render relief in all cases presented for emergency 
treatment. Grip the instrument with the thumb and first 

1 "Principles and Practice of Filling Teeth," Johnson. 



finger while the second finger forms a guard or fulcrum; 
then holding the instrument beneath the calculus, draw 
it on the long axis of the tooth away from the gums. 

Fig. 3. — Four scalers which can be used with success in removal of 
deposits on the teeth (side and front view). 

Figs. 4 to 8 demonstrate the position and protection 
of the lips, etc., with the left hand during this process. 

There is no fear of cavities under these deposits of salts, 
because their presence must have resulted from the exist- 


I I 

ence of an alkaline reaction and we have no caries except 
in acid reaction. 

Patients firmly believe at times, that cavities must exist 
on the lower anterior teeth where deposits have pushed 
the gums away and exposed the peridental membrane. 
This at times is very sensitive and too much force on the 
instrument, with too much pressure against the tooth, 

Fig. 4. — Method and position of the instrument and fingers for remov- 
ing deposits from the upper incisors. The position of the second finger 
of right hand will be noted as forming a fulcrum. 

should be avoided. There is no possibility of removing 
the enamel with the deposit, because it is merely a foreign 
matter attached to the enamel; and while it clings in many 
cases, it will be removed by perseverance and proper in- 
strumentation. The engine with bristle brushes and 
wooden poitits, rubber cups, etc., is ordinarily used after all 
the deposits have been removed, but this being only an 
emergency, the medicinal treatment should now be applied. 



Paint the edges of the gums, when they are inflamed with 
resorcin, 10 per cent, solution, tincture of iodine, or the 
counter-irritant tincture of iodine, tincture of aconite and 
chloroform equal parts; then give the patient a good anti- 
septic mouth wash. Instruct him how to use it in hot 
water, holding a quantity of same in the mouth, for a few 
minutes each time used, and on the following day to mas- 

Fig. 5. — Method of removing deposit from upper right side of mouth, 
showing protection of lips with left hand. 

sage the gums with the fingers. Then on the second day, 
have him use a small quantity of powdered pumice stone 
as a tooth powder and give the instructions on care of the 
teeth. Cleaning, not medicine and fancy mouth washes, 
aids nature most in reverting to the normal conditions. 
Instruct the patient in properly brushing the teeth, to 
place the bristles of the brush on the gums and by a down- 
ward or rotary movement of the hand, bring the bristles 



Fig. 6. — Showing position of instrument and first finger of left hand which 
prevents instrument from^slipping and injuring the gums. 

Fig. 7. — Position for removal of deposits from inner surface of lower 
central with use of the mirror. 



over the teeth. For the lower, the bristles will be placed 
on the gums and an upward or circular movement will 
give the same result, completing a circle with the brush. 
Then brush over the cutting edges and inside by the 
straight in and out motion. For the inside of the lowers 
use a lift movement of the bristles and brush the cutting 
surfaces, the same as the upper. Use floss silk for remov- 

Fig. 8. — Position of the instrument in removal of deposits from labial 
or outer surfaces of lower centrals, showing protection of the lips and ful- 
crum formed by second finger. 

ing particles of food between the teeth, where the contact 
points are bad and strands of food are held. Do not 
snap the floss silk down and injure the gums, in the inter- 
proximal spaces. The use of the wooden toothpick is 
injurious and absolutely unwise, as it works great havoc 
with the gums and the peridental membrane of the teeth. 
In case any pick is used, the quill is permissible, being soft 


and pliable and there is no chance of splinters being left 
to injure the gums. 

Many powders, liquids and paste tooth preparations 
on the market are more detrimental than nothing at all. 
A good paste makes the habit of cleaning the teeth more 
attractive and pleasant. The main point, however, in all, 
is the proper use of the tooth brush with plenty of water. 



Stomatitis. — A catarrhal inflammation of the mucous 
membrane of the mouth, which is divided etiologically 
into many classes. Marshall makes a classification as 
follows: u stomatitis simplex, stomatitis catarrhal, sto- 
matitis apthosa, stomatitis parasitica and stomatitis 
ulcerosa." This classification meets the demands of 
differential diagnosis very well indeed; however, only the 
local conditions, as a whole, will be dealt with in this 

The various causes of stomatitis are both local and con- 
stitutional. Among the local irritants are bad-fitting 
plates, bridges, crowns and fillings, and rough edges caus- 
ing irritation; also unhygienic conditions in bottle-fed 
children. Constitutional causes include malnutrition, 
conditions caused by unhealthy quarters, various dis- 
eases which alter the condition of the blood, as scarlet 
fever, diphtheria, scrofula; effects of medicines, such as 
the use of mercury, etc. There can be no doubt that para- 
sitical conditions of the mouth enter into this etiology. 

The surgeon in charge of the case should be consulted, 
as to the systemic condition. Its treatment, from this 
standpoint, should always be directed by him, especially 
as to changes of treatment causing this condition. 

Ill-fitting plates, bridges, crowns or fillings should be 
removed and not replaced in the mouth until the condi- 
tions are healed or repaired. 



The local treatment of nearly all cases should be as 
follows: The mouth should be irrigated with boric acid 
solution, Dobell's solution or other mild antiseptic, with 
a wash at some stage, always, of potassium chlorate, gr. v, 
to the ounce of water. Surfaces with glistening patches 
coalescing until the whole mucous membrane seems 
covered should be treated with emmolient lotions, such 
as borax and honey, glycerine, weak solution of acetate 
of lead, gr. iii, to the ounce of water, or a very weak solu- 
tion of alum. A few doses of potassium bromide will 
relieve the nervous condition. 1 

A great many men who live in barracks and eat the same 
prepared food will, at times, seem to present an epidemic, 
which is simple stomatitis. The irritated parts should be 
touched with resorcin, 10 per cent, or tincture of iodine. 
If the patient be given a good cathartic and advised to re- 
frain from the eating of meats, and given a glass of good 
strong lemonade, twice daily, for about three days, the 
normal condition will generally return. 

Herpes Labialis (Fever Blisters) . — An acute inflamma- 
tory affection, characterized by the formation of vesicles, 
or groups of same, on the skin or mucous membrane. 

Herpes is called fever blisters, also "cold sores," these 
names arise from the etiology, being frequent in all kinds 
of fevers and when the patient is suffering from a cold or 
intestinal indigestion. 

Forming blisters on the lips, they are very liable to be 
broken, and when they are they become very painful. 
The adjustment of the rubber dam and all other dental 
work over the lips, which might injure or bruise the tissues, 
cause their appearance and they may persist and recur, 
because some patients are of a herpetic diathesis. 

1 " Dental Medicine," Gorgas. 



Clean the affected part with alcohol or hydrogen 
peroxide and apply oil of cloves, or campho-phenique 
(the latter being much preferred). 

A large sore which is liable to break and bleed may be 
kept soft by the use of zinc oxide ointment. Very painful 
sores result from the vesicles breaking and from exposure 
to the wind, etc., and these raw surfaces should be washed 
clean with hydrogen peroxide or alcohol and then seared 
with campho-phenique and a thin layer of cotton placed 
over the part and this covered with Collodium. 

Canker "Sore Mouth." — Canker sores are very small, 
angry ulcers with a coating of whitish yellow over the 
surface. The size varies from that of a grain of wheat to 
a pea. They are generally located on the tongue, at its 
junction with the ground or floor of the mouth, as well as 
on the buccal surfaces at the duplicature of gums and 
buccal membrane. They vary in depth according to the 
stage of progress and are always painful, they are generally 
round and the margins well defined, but these must not 
be confused with the more perfectly defined margins of 
the chancrous ulcer. The membrane around the ulcer 
is always red and inflamed. Pressure within an inch will 
cause pain at the point of contact. The writer has ob- 
served them to appear suddenly in men, especially after 
excessive or unaccustomed use of alcoholic beverages, and 
they are common in pregnant women, appearing and 

Authors differ as to the cause of canker sore mouth, 
many believe their origin to be solely in the mouth while 
others attribute their cause to trophic disturbances. 1 
The duration, characteristic appearance, size, pain, and 

1 Pusey: quoted by Buckley. 


location of these ulcers renders diagnosis comparatively 


The mouth should be washed out with a good antiseptic 
mouth wash (the writer prefers it made with hot water, 
always), such as listerine, Dobell's solution, or 5 per cent, 
carbolic acid solution with a few drops of the oil of gual- 
theria or cassia, dissolved in alcohol, added; this held in 
the mouth for a minute or two. The ulcer should then 
be washed with a pledget of cotton saturated with perox- 
ide and the whitish-gray surfaces cleared off; the part 
should then be dried with alcohol and touched with a 
10 per cent, solution of nitrate of silver, which cauterizes 
.deeply enough, but does not penetrate too far, because of 
the forming of a firm coagulation. 1 A pledget of cotton 
saturated with pure carbolic acid will also be found very 
useful. The writer, after using one of these applications 
generally paints the inflamed area immediately around 
the ulcer with tincture of iodine, or iodine, aconite and 
chloroform, equal parts. The patient will be relieved 
immediately by this method and seldom requires a second 
treatment. The mouth wash should be continued for 
from twenty-four to forty-eight hours. 

Injuries of the Mucous Membrane 

Very severe injuries to the mucous membrane; inflamed, 
swollen patches and surfaces present; which are the re- 
sult of injuries to the tissues. The bristles of the tooth 
brush, may penetrate under the margins of the gums, or 
any other part with which the brush comes into contact 
in cleaning, and result in this condition to the extent of 

1 Prinz. 


forming an abscess. This may be mistaken for an abscess 
of the tooth, or a "pyorrhea alveolaris socket." The 
writer recently treated a patient, a young lady, who had 
been under treatment for six months for supposed dento- 
alveolar abscess of the upper right central incisor. It was 
considered incurable and she was advised to have the 
tooth removed. Careful exploration showed the pus com- 
ing from the side of the root, and presence of some for- 
eign substance under the gums about the middle of the 
root, which could not be removed. Incision was made 
opposite this point and a pus pocket opened. The con- 
tents were examined and a coarse bristle from the tooth- 
brush found. The abscess was treated, drained and 
closed, and the root filled, with resultant complete dis- 
appearance of condition. 

A hair, a bristle, a piece of a wooden toothpick, or a 
seed or any foreign substance of this class, may be found 
to be the cause of this painful condition. 


Removal of the foreign substance and the part washed 
with a warm mouth wash and touched with tincture of 
iodine, or aconite, iodine and chloroform, equal parts, on 
a pledget of cotton, will effect a cure. 

Smokers' Sore Mouth. — Many excessive smokers will 
present large, swollen, very red, dry patches on the roof 
of the mouth, extending over the palate, which are ex- 
tremely painful, in reality blisters. 


Wash the mouth with a warm solution of carbonate or 
bicarbonate of soda, or magnesia water, dry the surfaces 


affected with a pledget of cotton saturated in alcohol, 
then paint the surface with glycerite of tannin. Let the 

patient hold a 5-grain tablet of chlorate of potassium in 
his mouth until it dissolves, not chewing it, then in two 
hours, another one, and after that he will be able to smoke. 
If not repeat the treatment. 

Gingivitis. — Gingivitis is an inflammation of the gums 
and when the margins are so affected, as shown in Fig. 9, 
it is designated as " marginal gingivitis." 

In nearly all cases where marginal gingivitis, exists, we 
have a subsequent degeneration of the pericementum, the 
membrane of attachment of the roots of the teeth to the 
socket. This condition is almost certain, unless proper 
treatment is instituted, to result in a gingivitis of the 
deeper tissues and interstitial gingivitis, 1 as Talbot has 
wisely called the condition commonly known as pyorrhea 

Marginal gingivitis may be caused by local irritation, 
local infection and general effects of various origin, un- 
hygienic quarters, food, general debility, disease, drugs, 
such as mercury, etc.; gonococcus bacteria are claimed to 
have been found in some forms of gingivitis. 

In the case shown in Fig. 9, the patient had recently 
recovered from typhoid fever and showed absolute neglect 
of his teeth and mouth. Plaques of deposit, crowned the 
necks of all the teeth, these were covered by soft masses 
of decayed food, lying unmolested in a fermenting con- 
dition, far from the disturbances of mastication. The 
resistance to the treatment of this condition was proof of 
systemic involvement and bacteriological infection, aided 
by local irritation of deposits and food wedged between 
the teeth. 

Marginal gingivitis appears at the necks of the teeth, 

1 " Interstitial Gingivitis," Talbot. 



presenting a red, swollen, inflamed surface, which bleeds 
with the slightest touch, the gums are easily raised away 
from the deposit and are raw and very painful. 

Salivary deposits are generally present or some other 
mechanical object of irritation, such as ill-fitting crowns, 
fillings, plates, bridges, etc., or the existence of bad con- 
tact points, which permit the food to lie unmolested be- 
tween the teeth and result in a fermentation, irritating 
the gums to inflammation. Too violent brushing of the 

Fig. 9 — Marginal gingivitis; the result of neglect of teeth. Patient 
recently dismissed from hospital, case of typhoid fever. Mouth had not 
been treated or cared for, by his statement and by appearance. 

teeth and the use of too strong astringent mouth washes, 
will also cause the inflammation. 

When gingivitis appears in more than one or two places, 
that is, a general gingivitis on the margins of all of the 
teeth, it is usually the result of local irritation, salivary 

These irritated points form shelves between the margins 
of the gums and the tartar and present an ideal location 
for the fermentation of food, as well as an injured raw 


surface, open to the attack of the oral bacteria. The 
gums, pushed away from the necks of the teeth, are very 
spongy, very much swollen and congested, with irregular 
attachments to the teeth; and at times present a purple 
appearance, indicating excessive congestion. 

This condition treated and proper care of the mouth 
given by the patient will prevent subsequent development 
of the more serious and positive interstitial gingivitis or 
pyorrhea alveolaris. 


Local treatment will ease the condition and prevent 
further developments, unless an underlying constitutional 
condition is the cause. The following treatment will aid 
and be necessary even in the presence of the correction of 
this condition. Wash the mouth with a warm solution of 
half and half Dobell's solution and water; 5 per cent, 
phenol, or a weak solution of potassium permanganate or 
a solution of the mouth wash given below, then with the 
same method as employed in the removal of deposits, as 
shown in Figs. 4 to 8, remove the calculus and food debris 
from around the necks of the teeth and again flush out 
the sockets which appear at the margins. The gums will 
be very tender and tear, almost at the touch of the in- 
strument; but care will prevent this to any great extent 
and the profuse bleeding will help reduce the congestion. 
Take an orange wood stick, preferably, trim it to a flat 
surface and paint the rough raw surfaces with a 10 per cent, 
solution of trichloracetic acid, this will tend to reduce and 
astringe these affected surfaces. With a pledget of cot- 
ton, saturated with tincture of iodine, paint over all the 
affected parts. 

Give the patient a good mouth wash, such as: 


1$. Boroglycerinae, 1 

Tinct. of krameriae, 

Tinct. of calendulae, 

Alcoholis aa 30 c.c. 

Sig. — Two tablespoonfuls to a glass of water several times 

The writer has found this wash to have a very curative 
effect upon the injured tissues. Let the patient use this 
for one day after treatment, then proper care and brush- 
ing of the teeth, will, in most cases, prevent a recurrence. 

1 Burchard and Inglis. 


Syphilis will be dealt with, not from the standpoint 
of the general practitioner, treating the case, constitution- 
ally, but from that of the dental operator. Too much 
emphasis cannot be placed upon its importance to those 
who operate with the object of dental relief. 

Some men in the past have felt that they should not 
treat dental cases, where syphilitic symptoms were present 
or suspected. In our province of relieving pain, we can- 
not admit to a patient that we are not sufficiently cautious, 
skillful and informed to successfully treat him without in- 
fecting ourselves or our other patients. 

First-aid treatment in these cases, is as necessary and at 
times, more gratifying, than in many others. The writer's 
experience has been that syphilitics are exceedingly pleased 
to have rubber gloves used and all other precautions taken 
in treating their cases. One of the most agonizing cases 
of dental suffering the writer has ever treated, was a 
syphilitic, presenting abscessed teeth and necrosed roots, 
immediately under a large oozing mucous patch. The 
practice advocated by some men, of the destruction of in- 
struments after using in suspected syphilis, is expensive, 
useless, and foolish; since a good scrubbing with green 
soap and boiling in a sterilizer for not less than fifteen 
minutes, will suffice to make sure of asepsis. 

When we know that the patient has syphilis and he 
comes for dental treatment, precautions must be taken, yet 
the value of extra precaution must be considered in all 



patients, because we do not ordinarily know that patients 
are syphilitic. Syphilis is not a respecter of persons, sex, 
age, position or society and patients the least suspected 
may carry the spirochaeta of the scourge. 

Primary Syphilis 

The primary lesion of acquired syphilis appears from 
ten to ninety days, an average of twenty-one days after, 
and at the point of, infection. Appearing as an eroded, 
hard papule, losing its coating after a few days, it is raw, 
ulcerated and surrounded by a tough, hard ring. The 
lesion is called the chancre and is painless. The lymphatic 
glands lying in adjacent parts become swollen. 

The important point in this work is the extra-genital 
chancre, which appears so frequently on the lips, in the 
mouth, on the fingers, etc., and may be the direct result 
of ignorance or neglect in the care of instruments, appli- 
ances and the hands of the operator. Keyes gives a table 
of seventy cases of extra-genital chancres, which will 
serve to emphasize the importance of this fact by the 
various locations given: 

Cases Cases 

Males 70 Tonsils 2 

Finger 34 Cheek 1 

Lip . 24 Chin 1 

Tongue 4 Eyelid 1 

Abdomen. . 2 Arm 1 

Keyes states that almost all the finger infections are of 
doctors, due to contact with affected parts. Care of the 
hands as well as protection of patients is again emphasized. 
The treatment is constitutional and within the province 
of the general practitioner. 



Secondary Syphilis 

The secondary manifestations of syphilis will generally 
be observed in and about the mouth, irrespective of the 
location of the initial chancre. These are not local in- 
fections, but the result of the general progress of the dis- 
ease. The eruptions of this stage are found alike on the 
skin and the mucous membrane. Certain organs may 
show the result of acute inflammation. At the time of the 
fevers accompanying the eruptions, mucous patches occur 
on the mucosa of the mouth and in any part of the oral 

■■;-i -' 

Fig. 10 — Typical case of herpes labialis. (Cold sores or fever blisters.) 

cavity. The pharynx and the larynx are also affected 
by the inflammation. The copper-colored areas (like 
pus seen through a membrane over the point of a boil) 
appear under the outer mucous lining, on some part of the 
membrane of the lips, palate, buccal or labial regions, 
pharynx or tonsils. They soon break down and form the 
mucous patches which are the most virulent and danger- 
ously infectious lesions of the disease. 

This condition is of paramount importance to the oper- 
ator on the oral cavity, as the lesion can, at times, scarcely 
be diagnosed from the ordinary " fever blisters" (herpes 


labialis). Illustrations No. 10 and No. n show two cases 
which the writer treated for dental pain on the same day. 
Compare the vicious, painful patch of Herpes with the 
more innocent appearing, painless mucous patch. Diag- 
nosis of this condition at any time must be determined by 
other signs of syphilis, in other parts of the body, as en- 
larged glands, skin eruptions, areas of papular eruption 
on the membrane of the throat; also other signs, as falling 
out of hair, eyebrows, etc. Frequently a diagnostic sign 

Fig. i i — Syphilitic chancre. The one on the reader's right was full 
of pus just under the outer mucous membrane — the black spot indicates 
the yellow pus in the tissue. 

is that of indefinitely located dental pain. 1 The point 
of importance for the dental operator is to be able to 
determine these conditions and to take precautions for 
his patient's and his own protection; to refer the case to a 
general practitioner for systemic treatment if the patient 
is not under his care at the time. 

The use of mercury in these cases, is almost universal; 
even with the present use of salvarsan, mercury is and 
should be used as a following treatment. The appearance 

1 Hugenschmidt: quoted by Burchard. 

SYPHILIS IN II 1 1 : MOI 111 29 

of ptyalism has been much reduced by the new combina- 
tion. However, a prophylactic treatment of the oral 
cavity limits the possibility of ptyalism, and mercury can 
be pushed much further without salivation if the mouth 
has been placed in a proper condition. 

Tertiary Syphilis 

The lesions of secondary syphilis are confined principally 
to the mucous and dermal tissues but the lesions of the 
tertiary stage arise in the deeper connective tissues and 
the periosteum, most often attacking the bones with thin 
portions, such as the bones of the skull, palate, palatal 
process 1 and the alveolar process. 

Tertiary lesions will be noted by the oral operator in 
the form of ulcers, which appear first on the soft, then on 
the hard palate, on the lips, and on the tongue. They 
make their appearance usually as nodes under the skin or 
mucous membrane, and become larger as they approach 
the surface and break gradually through, forming an ulcer. 
This may perforate the palate and the extensive necrosis 
will at times totally destroy the bones of the surrounding 
parts. The more frequent affection in the mouth, how- 
ever, is the bone of the upper jaw. When the lower bone 
is affected, according to Marshall, it is generally in the 
alveolar process. He states a case where the palatal bones, 
the nasal bones and nearly the entire upper jaw, were 
destroyed, the soft palate being intact. 

These ulcers are malignant in the extreme and attack, 
impartially, every organ. Under treatment, systemic or 
local, they have very little tendency to disappearance. 
Authorities differ as regards the possibilities of infection 
from these lesions. Keyes states that "they are clinically 

1 Keyes. 


not infectious." However, an ugly, stubborn ulcer in 
the mouth of a patient should be looked upon with great 
caution and the same care be taken in operating and ster- 
ilizing, etc., as with other stages. Trauma, such as injury 
of dental tissues in treating the pulps of teeth, abscesses, 
pyorrhea alveolaris, extractions, etc., may be the cause of 
extensive necrosis in cases with a history of syphilis. It 
does not matter what has been the result of its treatment 
and the confidence of its cure. 

In case of accidental infection from an instrument used 
on a syphilitic patient, an ointment composed of ten parts 
of calomel and twenty parts lanolin, applied by inunction 
to the infected part, will probably prevent syphilitic 
infection if used within one hour of the inoculation. 
Mercuric chloride is claimed to be of no avail. 1 

Differential Diagnosis of Chancre and Herpes 
(Taken from Keyes) 

Syphilitic Chancre Herpes 

i. History: 
Sexual contact, kissing, mediate Relapsing herpes. , 
infection, vaccination, etc. 

2. Incubation: 

Two to six weeks. None. 

3. Commencement. 

Begins as an erosion or papula Begins as a group of vesicles, 

and remains an erosion or ul- rarely as a single vesicle, and 

cerates. ', becomes an ulcer. 

4. Number: 

Usually unique or simultane- Usually multiple simultane- 
ously multiple, rarely multiple ously and by successive crops 
by successive auto-inoculation, of vesicles sometimes confluent, 
never confluent. 

1 Metchinoff: quoted by Burchard and Inglis. 



Syphilitic Chancre 

5. Physiognomy: 
(a) Shape: round, oval or sym- 
metrically irregular. 

(b) Lesion: is habitually flat, 
capped by erosion or superficial 
ulceration; or scooped out, or a 
deep funnel-shaped ulcer with 
sloping edges. Sometimes the 
papula is dry and scaly. 

(c) Edges: sloping and adher- 
ent. Sometimes prominently 

(d) Bottom: smooth, shining. 

(e) Color: somber, darkish red, 
gray or black, sometimes livid 
and scaly, occasionally scabbed. 

(f) Secretion: slight, serosan- 
guinolent, unless irritation pro- 
vokes suppuration. 

8. Induration: Constant, 
parchment like and very faint, 
or cartilaginous and extensive, 
terminating abruptly not shad- 
ing off into parts around; 
movable upon parts beneath the 
skin and not adherent to the 
latter, outlasts the sore and re- 
main for months usually. 

9. Sensitiveness: Absent. 

10. Duration: At least a fort- 


(a) Shape: irregular, rounded 
with borders describing seg- 
ments of small circles left by 
confluent vesicles. 

(b) Lesion: usually superficial, 
sometimes in solitary Herpes 
there is but one absolutely cir- 
cular vesicle. There are usually 
neighboring vesicles to clear up 
the diagnosis. 

(c) Edges: sharp, not under- 

(d) Bottom: even, inflamma- 

(e) Color: like chancre. 

(f) Secretion: slight, seropuru- 

Induration: inflammatory, capa- 
ble of being produced by some 
cause as in the chancroid and 
behaving in a precisely similar 

Beginning, heat. 

Rarely more than ten days. 

Ptyalism (Salivation) 

In the treatment of syphilis, the administration of mer- 
cury is necessary in more than the tonic dose. In many 


cases the patient must be poisoned to cure the lesion. 
Mercury is an alterative and tonic in small doses but in 
severe cases of syphilis it is pushed far beyond this point. 
Mercurialism as shown by the gums, or mild salivation, 
indicates the stopping of its administration. The stop- 
ping of the mercury will, in these mild cases, affect a cure. 
Mercury has a selective influence on the gums, jaws and 
adjacent parts. 1 In more severe cases, the first symp- 
toms noticed by the patient are a coppery, metallic taste 
in the mouth, fetor of the breath, inflammation of the 
gums and swollen tongue, showing the imprint of the 
teeth. The gums bleed freely and a severe pericementitis 
of the teeth is present, with much pain when the jaws are 
forcibly closed. If the drug is not withdrawn, the condi- 
tion grows worse, saliva flows from the mouth, there is 
drooling and the tongue swells, teeth become so loose in 
the sockets that they may be picked out with the fingers 
(they should not be extracted, however). The glands 
swell and ulcerations occur in the mouth. Mercurial 
ulceration appears behind the lower incisors and back of 
the lower wisdom teeth; finally the soft tissue sloughs and 
necrosis of the bone sets in and sequestra form, whose 
subsequent removal is necessary. 


The care of the mouth for the prevention of salivation 
has been described above. Any patient who is to be given 
a course of treatment with mercury should have all irri- 
tating crowns, bridges, or plates repaired or removed, all 
roots extracted and be instructed to be conscientious in 
the brushing of his teeth and gums properly, at least three 
times daily; and be given a mouth wash, such as potassium 

1 Buckley. 


chlorate, gr. xv, dissolved in half a tumbler of water, for 
hardening the gums. 

The patient with a profuse ilow of saliva should be 
given refrigerating, acidulated drinks. The ulcerations 
may be touched with tincture of aconite, tincture of 
iodine, and chloroform or with: 

Tinct. of Myrrh. 1 

Tinct. Iodum Comp. \ aa 4 gms. 

Aquae J 

Sig: Apply to gums once or twice daily. 1 

Atropin in medicinal doses may be used by the physician 
in charge to control the excessive flow of saliva. The 
systemic treatment should not be changed except by him. 

When the evidence of necrosis is at hand and the parts 
can be treated, Mawhinney recommends the local appli- 
cation of 50 per cent, solution of phenosulphic acid, which 
acts as a stimulant and hastens the formation of sequestra. 

1 Buckley. 



In order to intelligently treat or relieve dental disturb- 
ances, it is necessary for the operator to have a knowledge 

Lower cent. 


4-7 months 

Lower lat. 


12-15 months 



18-24 months 

Lower first 


12-15 months 

Lower second 


20-30 months 

Upper cent. 


8-10 months 

Upper lat. 
8-10 months 

18-24 months 

Upper first 
12-15 months 

Upper second 
20-30 months 

Fig. 12. — The deciduous teeth and time of their appearance (left side 
of mouth only). — {From Broomell.) 

of the parts, their construction, relation, organs of supply, 
histology and functions. It is not intended to give in this 




chapter a full and extensive treatise on this large and im- 
portant branch, but to give a few ideas which will aid in 
all emergency treatments presented. 


Labial, view 

Third molar 



17-21 years 


Second molar 


12-14 years 


''-? H 

First molar 



5-6 years 
Second bicuspid 

**■ l ^9 


10-12 years 
First bicuspid 


_ _ 

9-10 years 


^ taHK ^' 

1 1- 1 2 years 
Lat. incisor 


4H^^ *si»ft»~ 

7-9 years 
Cent, incisor 

m** : 


6-8 years 



WKr- ' ****** 

n 1 


Lingual view 
Central incisor 
6-8 years 
Lateral incisor 
7-9 years 
1 1 -1 2 years 
First bicuspid 
9-10 years 
Second bicuspid 
10-12 years 
First molar 
5-6 years 

Second molar 
12-14 years 

Third molar 
17-21 years 

Fig. 13. — Eruption of the permanent teeth. — {From Broomell.) 

The temporary or deciduous teeth number five on each 
side, from the median line backward, the full set being 
ten in each jaw. These teeth erupt from the fifth to the 
thirtieth month and complete their full service with the 



eruption of the permanent set. The chart, Fig. 12, shows 
the time of eruption of the temporary teeth, and chart, 
Fig. 13, the eruption of the permanent teeth. Comparison 
of these figures and tables will show that the time of the 
loss of the temporary teeth is about that of the eruption 
of the corresponding permanent teeth. 

The importance of this comparison of the relative time 
of loss and eruption should be seriously considered in the 
decision as to the advisability of extracting deciduous 
teeth. Premature or delayed extraction may result in a 

Fig. 14. — The teeth in position with extreme alveolar plate removed, 
showing relative position of the roots. — {Johnson.) 

malocclusion and compel the patient, in a few years, to 
undergo the tedious process of regulation of the perma- 
nent set. Deciduous teeth should not be extracted when 
they ache any more than permanent teeth, but the treat- 
ment of the condition should be made to preserve the teeth 
for their full period of usefulness. 

Fig. 14, by Johnson, is an excellent exhibit of the two 
sets of teeth in situ. The external plates of the alveolar 
process being removed, the reader is able to secure an ac- 
curate idea of the angles, position and relation of the roots 
of the various classes of teeth, as they normally exist. 



Fig. 15 presents the diagram of the structure and im- 
plantation of the normal incisor tooth, a study of which 
will fix in the mind the exact anatomy and relation of 
the teeth. Those having multiple roots have the same 
histology and source of supply for each root. 



Dentinal tubulae 
Dental yrx i / j//^^\\ ft ^fev, V ' 

periosteum" *"" ~ ' ~* 



Opening at apex 

Bone of jaw 

Fig. 15. — Vertical section of an incisor tooth. 

The Enamel 

The enamel is the hardest and most compact part of 
the tooth, the part which forms the outer exposed surface 
and covers the crown. It is formed in prisms or rods, 
lying generally parallel to each other and resting at one 
extremity on the dentine. The rods are held together 
by a very minute layer of cement substance, presenting a 
solid mass to the naked eye. 

The Dentine 

The dentine is the tissue which forms the principal mass 
of the tooth. It is a modification of bony tissue, differing, 


however, in that the cells lie only at the periphery of the 
pulp, and not throughout the mass. The dentine is 
formed around the chamber which encases the pulp. The 
mass is traversed by small canals (dentinal canaliculi) 
which run in a course from the pulp outward, as is shown 
very clearly in the figure. These canals contain a sub- 
stance, called the intertubular tissue and communicate 
sensation from the point of stimulation to the pulp. The 
dentine is surrounded or covered by the enamel in the 
crown portion of the tooth, and the cementum in the 
root portion. 

The Cementum 

The cementum is the covering over the root portion of 
the tooth. It varies in thicknesses, overlapping the edges 
of the enamel at the neck, and becoming thicker over 
the apical portion. The cementum is truly a bone sub- 
stance, and contains Haversian canals in its thicker 
portion, about the apex. As age advances, the cementum 
becomes thicker, especially on the outer border. 

The Pericementum 

This membrane, for such it is, affords a lining for the 
alveolar sockets of the roots of the teeth. It also forms the 
attachment between the cementum on the inner surface 
and alveolar process on the outer surface, both of which 
it nourishes, being profusely supplied with nerves and 
blood-vessels. The fibers from the membrane form the 
firm attachment of the teeth in the socket; by entering 
into the substance of the bone on the one side, and the 
cementum on the other. The pericementum is larger, or 
thicker at the apical end of the roots. In the powerful 


concussion of the teeth in mastication this membrane 
acts as a shock absorber, so to speak. Being quite elastic, 
it permits the teeth to move about in their sockets. More- 
over the pericementum has a sensory function. It is the 
medium by which all forces applied to the tooth surface 
are taken up and conveyed to the brain. 1 

The important point in this brief description is the part 
played by this membrane in dental pain, by reason of 
its richly supplied nerves and blood-vessels and its 

The Dental Pulp 

The dental pulp, erroneously called the nerve, occupies 
the chamber or pulp canal, in the center of the tooth. 
It is not a nerve tissue, but fibrous cellular connective 
tissue, and is abundantly supplied with blood-vessels and 
nerve fibers. These gain their entrance through the 
opening at the apical end of the root, or roots. As the 
tooth may have a different number of roots, so it must 
have a corresponding number of apical openings for the 
supply of the vessels and nerves. 

The pulp serves as the menstruum for holding the odon- 
toblasts, or dentine-forming cells, which lie at the periph- 
ery, the pulp being forced back as the process of dentine 
building continues, until, in old age, the pulp chambers 
are nearly closed and the pulp receded. 

The vessels of the pulp are very numerous, entering the 
apical foramen in three or more branches 1 they form a 
plexus which is the cause of the profuse bleeding from 
the pulps, in their removal. 

The nerves generally enter by one large trunk and three 
or four minute branches. After pursuing a parallel course, 

1 Broomell. 


giving off branches in the body of the pulp, they form a 
rich plexus beneath the edges of the developing dentine. 1 
The relationship and the structure of the dental pulp must 
be understood, for intelligent treatment of the greatest 
of maladies in emergency treatment. 

The Alveolar Process 

The alveolar process of the maxillary bones, is a 
strong and wide ridge of bone, which forms the root 
sockets. The alveolar process consists of two plates, 
an inner and an outer; and these are connected by septa, 
which separate the sockets of the teeth. A process of a 
jaw without the teeth, looks like a solid bone, with the 
sockets drilled out for the respective roots of the teeth. 
The bone in the septa has a soft, spongy structure, very 
easily broken and many times septa are carried out be- 
tween the roots of the teeth, in extraction. The upper 
edges are thin and vary in width at different teeth; viz., 
over the cuspid teeth, the bone is thinner than in any other 
part and fractures are frequently located here by reason 
of this fact. The process at the outer surface of the lower 
third molar teeth is very short and thick and at the inner 
surface, very thin (a point to be remembered in extrac- 
tions) . The reverse is practically true of the upper third 
molars. This process being spongy and sharp at the 
edges, is easily broken down, after the tooth it supports 
is removed. 

The Gums 

The gums are continuances of the mucous membrane 
of the mouth, differing from other membranes by their 

1 Tomes. 


greater density, being composed of fibrous tissue. The 
gums are hard and elastic and closely connected with the 
periosteum of the alveolar process, seemingly a con- 
tinuous tissue. The gum tissue is scantily supplied with 
nerves and sensibility is limited. Its ability to reconstruct 
or rebuild itself after injury is marked. 


The pain presented being proved not to be a result of 
calculus, stomatitis, gingivitis, etc., of the foregoing chap- 
ters, or of pyorrhea alveolaris or neuralgia, it will be pain 
from the individual teeth. Toothache, in the words of 
the poet, Burns, "The Hell of all Diseases," to be suc- 
cessfully treated must be properly located and then diag- 
nosed as to the cause when it is a simple matter to effect 
the cure. 

There are several kinds of toothache, which are the 
results of various causes, which will be studied in order to 
accomplish what we are called upon to do. 

(Inflammation of the Dental Pulp) 

A tooth may ache from an exposure of the pulp, where 
the structures have been dissolved out and undermined 
and the germs of decay have opened a path for various 
irritations to the pulp-tissue, a point of irritation and 

The pulp may also be exposed and inflamed under a 
leaky filling, or one which has been placed in the tooth 
without proper removal of decay or sterilization of the 

Pulp exposures may result from the injudicious use of 
strong acids, which have been pumped into pockets under 
the gums, in the treatment of pyorrhea alveolaris. The 



tooth structure will be destroyed and obscure cavities 
form which will be very hard to find. Errors in diagnosis 
are very liable to occur in these cases. 

Another is by mechanical abrasion, the teeth become 
worn and in older persons, the enamel entirely ground 
away, the dentine grooved and the pulp exposed. In the 
writer's practice, a man sixty years of age, with apparently 
sound teeth, from the labial view, could not close his mouth 
because "He felt it was close to the quick. " The lingual 
or inner part of the upper right central was so worn and 
grooved by the lower that the nerve was entirely exposed. 

The pulps may become exposed, also from fractures of 
the teeth, either by forcibly bringing the jaws together in 
a way to split them or by a blow. Many times a pulp 
will become inflamed and die without the patient knowing 
it, from' the result of a slight injury to a tooth. 

There is another pain which we find in a live tooth, the 
' formation of pulp-stones, or rather secondary dentine, calco- 
spherites. The dentine cells not being forced to the 
periphery, mass in the body of the pulp. This is a very 
confusing and tedious condition to diagnose and treat. 
Fortunately emergency treatment except that used in 
pulpitis, will not be necessary. 


(Exposure of the Dental Pulp) 

When this condition exists, the pain is such that the 
patient will, in most cases, have no doubt as to the tooth 
affected. Nevertheless, exploration should be made with 
a mirror and a sharp fine explorer. When the cavity is 
found, press the tooth gently, but firmly, with the finger 
and tap it with an instrument. This will not cause in- 
creased pain, because the peridental membrane is not 


affected. Heat, carried by means of a small piece of gutta- 
percha, heated in an alcohol flame, held in a pair of dress- 
ing pliers, applied on the enamel, will intensify the throb- 
bing; as will also lowering the head, since either increases 
the congestion of blood in the already hyperaemic pulp. 
A very slight amount of cold may be applied by a small 
stream of cold water from a syringe, where there is doubt, 
and this will more than intensify the pain. The history 
of the tooth, as to injuries, mechanical irritants and treat- 
ments of pyorrhea alveolaris, will be taken into consider- 
ation in determining this condition if the above methods 

Putrescent Pulp 

The difference between life and death, in any tissue, 
organ or body, is very comprehensible and makes a great 
classification. In regard to the dental pulp, it is the most 
important point in determining the trouble and treat- 
ment. Patients will present with swollen jaws, from 
dento-alveolar abscess and remark that the " nerve is ex- 
posed." Such a fallacy will readily be seen, as the tooth 
cannot be abscessed, except by the death of the pulp. 
Death of the pulp is preceded by the process of inflam- 
mation. Irritation causes hyperaemia, which is one of 
the first causes of pain, in pulpitis. Following this, patho- 
genic bacteria enter and the decomposition of the pulp 
sets in, literally, the death. 

This condition of the pulp is the beginning of various 
kinds of diseases. Septic pericementitis, dento-alveolar 
abscess, etc. By the decomposition of the complex sub- 
stances of the dental pulp, two gases are formed, ammonia 
and hydrogen sulphid. Poisonous ptomaines and fats are 
also found, the result of putrefaction; this condition is the 
putrescent pulp. 


Putrescent pulps form as a result of caries, fractures, 
thermal changes, teeth carrying large fillings and other 
conditions, which cause the irritation and inflammation 
of the pulp associated with infection. The gases held in 
the pulp-chamber, unable to escape through the tooth, 
result in the formation of a septic pericementitis, or a 
dento-alveolar abscess, by forcing septic matter through 
the apical opening. 

Putrescence (the presence of gases) is the result of in- 
flammatory process, with putrefaction, fermentation, and 
infection from bacteria, in the pulp-chamber. 


The anterior teeth are more easily diagnosed, when 
putrescent pulps exist, because there is less possibility of 
a partial life and death of the tissues, than in the multi- 
rooted teeth; and reflection of light through the tooth is 
more readily accomplished. These teeth present a bluish 
or brownish discoloration through the larger part of the 
pulp-chamber and hot instruments or gutta-percha have 
no effect nor has the application of cold to the surfaces of 
these teeth. If the cavity is open, the patient will notice 
a bad odor and taste from the leakage of gases and septic 
matter. As a rule, there is no soreness at the end of the 
roots, but pressure will make the patient feel, at times, 
the abnormal condition of the tooth, which is generally 
not loose. The gases which escape from these teeth, upon 
the opening of the chamber will be sufficient to prove the 
diagnosis. The odors of hydrogen sulphid and ammonia 
and of the putrefaction, will need only be smelled once, to 
be always recognized as those of a putrescent pulp- 

46 first aid dentistry 


Pericementitis is the inflammation of the peridental 
membrane of the tooth and is divided into two classes: 
non-septic and septic. The non-septic is caused by me- 
chanical or drug irritants 1 such as root fillings, ill-fitting 
dentures, plates, crowns, bridges, the hammering in the 
insertion of large gold fillings,, or crowns left too long, 
causing a pounding on the tooth in occlusion; and drugs 
used in the treatment of these teeth. 

Diagnosis — Non-septic Pericementitis 

In pericementitis, not caused by the presence of septic 
matter or bacteria, we have an inflammation of the deli- 
cate vascular membrane which swells and enlarges and 
pushes the tooth slightly from the socket. The peri- 
cementum is the tactile organ of the tooth, and when 
inflamed it is extremely tender to percussion. The dif- 
ference to be found between septic and non-septic peri- 
cementitis will generally depend upon the history of the 
operations on the tooth, as to the treatment and filling 
of the root canals. There is no pus formation in the non- 
septic pericementitis. When percussion is applied, there 
is a dull sound; and we find a deeper color in the gum 
tissue. 2 

Acute Septic Pericementitis or Acute Dento- 
Alveolar Abscess 

The septic diseases of the pericementum are almost 
invariably the result of infection from suppuration and 
gangrene of the pulp or that from the oral cavity, through 

1 Buckley. 

2 Burchard. 


the pulp chambers and root canals of dead teeth. The 
latter cause is most frequently a result of carelessness of 
the operator in forcing septic matter into the apical space 
with a broach. It is very questionable whether pyorrhea 
alveolaris pockets cause this condition, by their proximity. 
The writer prefers to believe this supposed condition to 
be an extension of the pyorrhea alveolaris itself. Acute 
abscesses are prone to occur under the above conditions 
when a patient " takes cold." 

The inflammatory process is the same in the dento- 
alveolar region as in any other tissues of the body, the 
infecting organisms produce the same condition at the 
apex and in the apical tissues. Hyperemia follows the 
primary infection and sensation in the tissue is altered by 
the resultant pressure. 

Upon the entrance of this matter into the apical tissues, 
and the further process of inflammation, the pain is very 
great because of the abnormal pressure on the sensory 
nerves; and the swelling of the part forces the tooth from 
the socket. This increases the pain and irritation, by 
contact with the opposite teeth. The next stage is the 
formation of pus by the degeneration of the apical 
tissues. Throbbing pains, which are extremely depress- 
ing result from the pressure of the pus-irritation and the 

The next process is the exit of the pus through the tissue 
which offers the least resistance; usually through the outer 
alveolar process, the thinnest part. The pain is very 
severe during the time of this boring of the pus for an 
exit; but when it has accomplished the destruction at 
the point of advance, the pain reduces, the soft tissues 
offering much less resistance than the bone. There is a 
great difference in patients, in many the tissue will not 
give way so readily. Extremely large and unsightly 


swelling results. With abscesses on the upper teeth, the 
eye on the side affected becomes almost closed and the 
cuticle is shiny and tight. 

In some cases the pus burrows through the bone and 
out through the gums and breaks within the mouth, with- 
out any swelling of the face. Some pus tracts will not 
make the exit in the mouth but will wend their way down 
the neck or out on the face. In many cases, the point of 
the abscess will not break through the mucous membrane 
in the mouth, which appears to be tough and resistant. 

From an opening being made by lancing these abscesses 
will, in the majority of cases, freely discharge and evacu- 
ate the full tract. The pressure of the blood system will 
be evidenced by the spurts of pus with each heart beat. 
The formation of abscesses in patients suffering from sys- 
temic diseases may be the beginning of complications, 
causing the formation of necrosis of the bones, etc. 


In the beginning of an acute alveolar abscess the pa- 
tient will feel an uncomfortable condition at the apex of 
the tooth, or rather in the deeper gum tissue around the 
tooth. He may experience reflex pains and not know 
which tooth is aching, but in the majority of cases pre- 
sented there will be no question, the pain being localized 
in the tooth or directly at its apex. There is usually a 
smoky dark discoloration noticed, and the pressure of pus 
and a darkened color of the gum tissue over the roots of 
the tooth. No response to thermal changes will be 
noticed. The tooth will usually be elongated and loose, 
contact with other teeth being very painful and sometimes 
impossible. Percussion or tapping a tooth in this con- 
dition is only useful where it is not protruded or loose, 



as the diagnosis of the acute abscess will be fully deter- 
mined by the above observations. 

Chronic Alveolar Abscess 

A chronic alveolar abscess is, as the name implies, a 
chronic abscess condition, in which the pus continually 
forms by the alternate formation and breaking down of 
apical tissues and granulations with the expulsion and 
drain of pus. The principal cause of this condition is 
originally the acute alveolar abscess, described above, 

Fig. i 6. — Chronic dento-alveolar abscess one root of upper, left, first 
molar. Radiograph. — (Author's practice.) 

and the causes of the former will be considered the same 
as those of the latter. 

There are two kinds of chronic abscesses: those without 
an opening, except as a drain may form through the root 
canals of the tooth; and those which are discharging 
through a sinus or fistula. 

The first class may drain into the mouth for months and 
not give the patient any pain or annoyance, because the 
canal of the tooth offers an exit. The drain is natural 
and has no resistance to its discharge; but when the root 
canals or pulp-chambers become stopped up and cut off 
the tract, swelling and reaction becomes prominent. 


The chronic abscess is generally found to be on only one 
root of a multi-rooted tooth, all three roots of a molar, 
for instance, will not be affected. (See Fig. No. 16, 
radiograph, upper first molar.) 

The tract of an abscess of this kind is lined by cicatricial 
tissue, which is formed in the abscess cavity and lines the 
tract to the end of sinus, generally on the buccal or on the 
outer jaw surfaces. 

The tract may be compared to a blood-vessel, as the 
pus will lead directly from the central sac through it to 
the opening, the mouth of which may not be directly 
opposite the tooth affected. It may course down the sides 
of the bone and open opposite an innocent tooth. The 
general rule, however, is to open over the diseased tooth. 

The pus in abscesses of the upper molars and bicuspids 
may, however, bore into the Antrum of Highmore, at the 
points where the bony process of its floor is thinner and 
offers the least resistance to the exit of the infection. 

In the lower teeth, gravitation is always to be consid- 
ered. The pus may bore through the body of the bone and 
cut on the face or chin. An impacted tooth may be the 
cause of a chronic abscess. With the lower wisdom teeth 
this is a common cause, the fistula here nearly always 
making its appearance through the inner plate into the 
mouth, or at the side of the tooth through the socket. 

So much pus and the process of building up and tearing 
down of the new tissue, in many cases causes a necrosis of 
the bone, or alveolar process, at this point. It may form 
without the patient's being conscious of any trouble, 
except the appearance of a "gum boil" as he calls the 
teat of the fistula which recurrently fills and breaks. 
The complications of the chronic alveolar abscess demand 
attention and permanent treatment more than any other 
tooth affection. 



The stopping of the discharge of pus through the teeth, 
will be very difficult. When it is evaluated in treatment, 
it will probably persist and appear to come from an un- 
limited supply, which thus aids the diagnosis of the chronic 
condition to a great extent. The probe will pass an amaz- 
ing distance through the external opening into soft tissue, 
without any apparent resistance, which shows the presence 
of destruction of the apical structure. 

The diagnosis of the chronic dento-alveolar abscess is 
comparatively easy. When the patient has had pain in 
the tooth and the tract points into near-by tissue, it ap- 
pears and discharges by one, two or three small openings, 
very close together. The use of a fine silver probe to 
find the direction of the tract and tooth affected will 
serve where there is question. 

The X-ray will serve admirably here and the history of 
the tooth as to treatment, the pulp removed, root fillings, 
etc., will aid materially. The fact that it carries a filling 
or crown, etc., or has been treated, roots filled, only adds 
to the suspicion that it is the tooth affected. 



The first consideration in the treatment of the patient 
is the instruments, their care and use. Figs. 17 and 18 
show the instruments which the writer believes to be neces- 
sary in the treatment of emergency cases. A mirror, 




Right and 
left spoon 

Fig. 17. 

dressing pliers, explorer, chisels, excavators, broaches and 
plastic instruments. 

There should be no question in the sterilization of these 
instruments, they should be boiled in water a sufficient 
length of time and brushed clean, with the exception of the 
mirror. Have a clean glass or receptacle for a 10 per cent. 




solution of formaldehyde, with a small amount of borax 
to prevent rust, in which to dip these instruments and to 
sterilize the mirror, wiping dry with a clean towel before 
placing in the mouth. The use of these instruments will 
be explained and illustrated in the following treatments. 
When a patient has had a severe toothache, in all 
probability he has neglected his teeth. Foul odors from 
fermenting food and a bad taste will be present and this 






Fig. 18. 

is where we must make the sitting agreeable. A warm, 
body temperature solution of one of the following anti- 
septic mouth washes, used in a syringe, will be found to 
deodorize and stimulate the patient's mouth. He will feel 
grateful and it will be more pleasant to work in the 

Dobell's solution, 50 per cent, in hot water, or 5 per cent, 
carbolic acid, with a few drops of oil of wintergreen or 
cassia, dissolved in alcohol, added will make a very pleas- 
ant wash. Listerine is fairly good used in this manner. 
A good astringent and antiseptic is as follows: 


fy Boroglycerinae, 
Tinct. krameriae, 

Tinct. calenduale 01 

Alcoholis. , aa 30 c.c. 

Sig. — One or two teaspoonfuls in glass of water. 

It has been said that the way to stop a tooth with an 
exposed pulp from aching, is to take it in out of the wet. 
This is correct and must be borne in mind in sealing the 
medicine in the cavity. 

In choosing the proper drug then, we must find one 
that does not dissolve easily in water. For this reason 
cocaine or eucaine and other drugs requiring a solution to 
carry them or agents that are freely soluble in water, 
cannot be expected to keep the tooth from aching, because 
they wash out, although they will relieve temporarily. 
What we want is a drug that has anaesthetic and disin- 
fectant properties and is sparingly soluble in water. 

The following may be used, preference in the order 
named: campho-phenique, carbolic acid, eugenol and 
oil of cloves. There are many others but this number will 
suffice, since the emergency case will contain at least one 
of the above. 

The pain from which the patient is suffering having been 
diagnosed as pulpitis from exposure of the pulp; the 
preparation for its treatment will be made. The operator 
must be cleanly and have his hands free from dirt or infec- 
tion, beyond doubt in the patient's or his own mind. 
Open the mouth gently, use a warm solution of a pleasant 
mouth wash forced through a syringe and have the parts 
as clean as possible. Place the mirror over the tooth and 
locate the cavity, then with a small pledget of cotton wipe 
the tooth dry as possible, observe the food particles which 
may be present and with a warm spray flush them from 
the cavity. Take two cotton rolls about the size of the 



second finger; place one on the outer side, between the 

lips or check and the gums, the other clown well between 
the tongue and the gum margins and hold in place by 
the mirror, as shown in Fig. 19. For the upper teeth, 
only one roll will be necessary, placed on the outside of 

Fig. 19. — Method of excluding saliva while placing dressing in a cavity. 
Rolls placed on either side of tooth and held in place by mirror while 
the cavity is dried. 

the teeth, it will be held in place by the cheek or buccal 

Dry the cavity gently with cotton, and with an explorer 
ascertain the point of exposure. Do not force the explorer 
into the pulp. With a spoon excavator, shown in Fig. 



20, remove the leathery decay as much as possible, 
drawing the instrument away from the pulp-chamber. 

Dry the tooth again with a loose pledget of cotton. 
Prepare all the following pledgets of cotton rolled to the 
proper size and have the bottles containing the drugs to be 
used, open on a table where they are within easy reach. 
Saturate the first and smallest pledget in one of the above- 

Fig. 20. — Removal of decay with spoon excavator. 

mentioned remedies and place in the cavity as shown in 
Fig. 21. Then without removing the mirror, cover 
this with a slightly larger, loose pledget, then dip the 
larger one, which is slightly smaller than the cavity, in 
sandarac varnish or vaseline and place over the cavity. 
Take the first finger of the right hand and after dipping it 
into warm water, gently press the varnished or vaselined 
cotton as is shown in Fig. 22. Where the pulp is nearly 



exposed, this will be found more desirable than the use 
of the gutta-percha stopping, because of the difficulty 
in avoiding pressure, which will cause as much or more pain 
than before treating. Creasote should not be used in these 
teeth because it is supposed to be lacking in the properties 

Fig. 21. — Placing medicine on pellet of cotton in the cavity of the tooth, 
protecting lips by ringer of hand holding tweezers. 

In case the tooth has been aching for two days or more 
you will expect to find a pulp congested with blood. In 
this case puncture the outer membrane slightly and permit 
the blood to ooze out. The cotton rolls and mirror being 
placed as described above, the bleeding can be permitted 


and the blood absorbed with cotton pledgets and then one 
of the above treatments applied. 

Should the cavity be located between the teeth and the 
enamel be standing, but undermined, it will be neces- 
sary to take a broad chisel, as shown in Fig. 23 and 
break down this covering, so good access can be had to 
the cavity. Care must be taken to prevent the slipping 

Fig. 22. — The tooth treated and medicated cotton covered by Sandarac- 


of the instrument into the cavity by the guard of the 
second finger on the surface of the tooth as is shown in 
Fig. 20. 

In case the exposure is not complete, the tooth should be 
treated in the above manner and the surface of the cavity 



seared with one of the drugs given, as the effect of the drug 

will be carried through the dentinal tubules to the pulp 
tissues. See Fig. 15 (Brief Dental Anatomy). 

In cases where there is a filling, either firm or partially 
loose, difficulty will be experienced in removing it without 
a dental engine drill, but this can be done with chisels, in 

Fig. 23. — Method and position in breaking down enamel with a chisel, 
showing fulcrum and guard of second finger. 

the same manner as described above in breaking down the 
enamel. The margins being broken, the filling is pried and 
lifted out with the spoon excavators, and the treatment 
applied as above. 

When pain presents from mechanical abrasion, the 
enamel is worn away and the dentine is exposed or the 
ends of the dentinal tubules are exposed and the inter- 
tubular substance transmits irritation to the pulp. 


Place cotton rolls to protect the gums and with a pledget 
of cotton saturated in a solution made by dissolving a 
small crystal of silver nitrate in a drop or two of water, 
sear the part. Keep the mouth open a few minutes, then 
remove any surplus with a cotton pledget. 



The aim of the dental operator in treating putrescent 
pulps is to afford an escape for gases and use a drug which 
will destroy or change them into a solid or liquid and pre- 
vent pressure. Buckley gives three important factors 
which must be accomplished, viz.: i. Establish asepsis. 
2. Prevent recurring sepsis. 3. Preserve and restore the 
color of the teeth. The course to be pursued by the opera- 
tor in treating emergency cases, will conform to the above, 
except in the last point, the third factor " restore color/ 7 
which will be left to the dental surgeon, not being con- 
sidered an emergency. 

The mouth should be treated in the same manner as 
described above in preparation, by flushing it out and 
cleaning the teeth. It is proper to apply the rubber dam 
over the tooth and adjoining teeth and disinfect with 
formalin solution, described in the preceding chapter for 
use in dipping instruments, but this will not usually be 
attempted by the operator in emergency cases. 

The cotton rolls will be used as previously shown and 
described and the tooth will be washed with a large pledget 
of cotton saturated with alcohol. The opening into the 
pulp-chamber will now be made and the chisels described 
in the foregoing chapter will be used, in case the cavity 
has been filled and access cannot be made by the use of the 

In cases where the tooth is sound and has no weak mar- 




gins it will be almost impossible to make an opening with- 
out a dental engine burr, but these cases are infrequent. 

The cavity being opened, the pulp-chamber should now 
be entered and this can easily be done, where we have 
access, with a spoon excavator. The opening should be 

The chamber should be enlarged sufficiently for the 
mouth of the canals, as the tooth may be single or multi- 

Fig. 24. — Putrescent pulp, showing manner of opening root canal mouth 
with a broach. 

rooted, to be opened by the point of the broach. Fig. 24. 
Do not run the instrument through the canal, merely 
place it in the opening to be sure that the mouth is not 


Take a small pledget of cotton and saturate it in the 
following remedy: Cresol and formaldehyde, of each equal 

parts. Touch it to a towel to remove the excess of the 
liquid and place in the pulp-chamber in the same manner 
as given in the previous chapter. A loose pledget of cot- 
ton saturated in an oxyphosphatc cement filling, mixed 
very thin should be used to seal the cavity. This will not 
be convenient in many cases and a sandarac varnish dress- 
ing may be placed over the cavity. It is better not to 
seal this cavity with gutta-percha stopping, because of 
the difficulty in avoiding pressure and forcing the remedy 
through the canals. Such an accident will cause a very 
painful toothache for which nothing can be done, except 
to force warm antiseptic water into the chamber, in the 
hopes of diluting the drugs. However, it will generally 
not ache more than half an hour. 

This treatment will be sufficient for three or four days, 
and if the patient requires further treatment the dressing 
can be removed and in the same manner the tooth pre- 
pared for re-dressing, as above. The canals may now be 
cleaned with a small broach and the treatment again 
sealed, this time wdth the gutta-percha stopping. Smooth 
this with a pledget of cotton saturated in chloroform. 

Dr. Buckley is responsible for the perfection of this ex- 
cellent cresol and formaldehyde treatment, the chemistry 
of which makes it the rational treatment: The gases am- 
monia and hydrogen sulphid of putrescent pulp uniting 
with formaldehyde, urotropin and methyl alcohol and 
sulphur, are formed. Basic ptomaines, unite with for- 
maldehyde forming inodorous compounds. The cresol 
(tricresol) is a disinfectant and saponifies the fats. This 
treatment is used almost universally by dentists and has 
eliminated to a very great extent the older and inefficient 
methods of treating this condition. 

64 first aid dentistry 

Non-septic Pericementitis 

• In the emergency treatment of this condition, the drug 
irritants which have been used in the pulp extirpation, 
devitalization and preparation for root filling will have 
had their effect and this cannot be removed, so relief must 
be administered. Mechanical irritants, however, such as 
ill-fitting plates, crowns, bridges, fillings, etc. (except root- 
canal fillings), can be removed. It is ill advised for any 
except the dental surgeon to attempt to remove a root- 
canal filling. Crowns or fillings that are left too high 
may be ground down to relieve the condition. 

Immediate relief must be accomplished by the applica- 
tion of drugs and remedies. When a tooth is very sore 
and has been diagnosed as non-septic pericementitis, one 
of the ways to relieve it temporarily is to place a silk dental 
floss around it and slightly pull from the socket. The 
slight pulling alters the tension in the peridental mem- 
brane. It is then a matter of counter-irritation. Wipe 
the gums as dry as possible around the tooth. Take a 
pledget of cotton soaked in tincture of iodine tincture of 
aconite, and chloroform, equal parts, and paint this dry 
surface, holding the lips and cheeks away until the evap- 
oration ensues. Blowing the surface with a chip blower 
also adds to the effect. 

The patient may be given a small amount of this mixture 
to paint over the parts, and carefully instructed as to the 
quantity necessary, etc. Another counter-irritant recom- 
mended by Buckley for this is a split raisin, first soaked in 
hot water and dusted with red pepper, applied to the gums 
over the tooth. Another remedy for the patient to use 
is the holding of water, as hot as can be borne, around the 
tooth. A foot bath, the patient holding his feet for fifteen 
or thirty minutes, in very hot water, is an excellent remedy. 


Acute Alveolar Abscess. — A knowledge of the pathology 
is more necessary in treating this condition than any other 
we find. The treatment of acute alveolar abscesses should 
be abortive in the first stage of the inflammation and pus 
formation, and in the second stage up to the time the pus 
perforates through the alveolar process. 

The local treatment is to flush clean and sterilize the 
patient's mouth with the washes advised before; clean 
and dry the part and place the cotton rolls as previously 
described. Enlarge the cavity in the tooth until the pulp- 
chamber is opened and with the excavator remove the 
debris in this part until the root canals can be entered. 
Take a broach and enter these canals (Fig. 24). Spon- 
taneous relief from the pain will be noticed when the pus 
begins to make its appearance into the cavity. An as- 
tonishing amount of pus frequently exudes from the apex, 
five or six drops at a time rushing from the canal. Let 
this continue to drain. At the first sitting, place a pledget 
of cotton, saturated in formalin and cresol solution (the 
excess being removed by touching to a towel) in the bot- 
tom of the cavity; cover this with a loose dressing of 
cotton, soaked in sandarac varnish or vaseline. 

At this stage a good counter-irritant may be placed over 
the gums around the apex (tincture, of iodine, tincture of 
aconite and chloroform, as given in the preceding chap- 
ters). The abortive treatment should be instituted for 
this stage, a good saline cathartic, as Epsom's salts, or 



magnesium citrate will prevent an accumulation of blood 
in the part. An excellent alterative can be given, viz., 1 

fy Potassii iodii 6 gms. 

Syrupus sarsaparilla comp 90 c.c. 

Sig. — Take a teaspoonful in water after meals. 

In most cases the pain will subside after the tooth has 
been treated and the pus evacuated from the cavity, but 
when the patient is nervous and has lost sleep a good drug 
to be administered is acetanilid, which may be given in 
the following form: 2 

1$. Pulveris acetanalidum comp 0.5 gm. 

Syrupus simplex 15.0 c.c. 

Spiritus frumentii q. s. ad 90.0 c.c. 

Sig. — Take half at once and remainder in two hours if necessary. 

When it has been decided that pus has formed and is 
external to the alveolar process, which can be determined 
by pressing the finger gently over the part, the treatment 
of the tooth proper should be the same and the abortive 
treatment will be altered by the judgment of its necessity. 
The counter-irritation should not be applied to this outer 
surface, under any circumstances, at this time, for fear of 
driving the pus toward the inner wall and into the Antrum 
of Highmore. Take a lancet, lift the lips and hold clear 
of the operation, touch the point of the abscess with phenol 
on the instrument and then force the bistory into the tis- 
sue and force it deep, until it touches the alveolar process 
plate; move it around in the region until the end finds the 
point of perforation. When this has been drained and all 
the pus is forced out that can be at this sitting, take a 
small bundle of cotton fibers, roll very tight, dip in phenol 
and with a pair of tweezers force to the bottom of the tract 

1 Buckley. 

2 Harlan lectures. 


and remove. This will take the soreness out of the tissue 
and cauterize the opening for subsequent escape of pus. 
The patient should be directed to wash his mouth fre- 
quently with one of the washes given before and holding 
some of the solution in his mouth, to gently massage the 
swollen part of the face. 

The practice of painting the swollen surfaces outside 
the face with tincture of iodine is good, but it is unsightly 
and the swelling will generally go down in twenty-four to 
forty-eight hours after the first treatment. The old 
method of poulticing on the outside of the face is absolutely 
uncalled for and criminal. 

Chronic Alveolar Abscesses 

Chronic abscesses, without sinus: The chronic abscesses 
are, unfortunately for the patient, not so painful and 
therefore demanding emergency treatment. 

The treatment of the chronic abscesses, without fistula 
is different somewhat from the procedure in the acute 
abscess, in that the apical opening is entered freely and 
the contents of the socket stirred to forcible expulsion. 
The same method of sterilizing the mouth and the use of 
the cotton rolls and opening the cavity will be followed in 
this case. 

When the canal is opened, there is already a pus sac at 
the apex and the broach may be forced through into it. 
Pressure may be applied over this apical part and the pus 
forced through the canals. These are now cleaned and a 
loose pledget of cotton, dipped into phenol, placed in the 
cavity and covered with vaselined cotton. The next 
sitting, the cotton will be removed and will probably be 
saturated with pus, which has formed since the first sitting. 
Drain again, as before and then place a pledget of cotton 



saturated with the formalin and cresol solution into these 
canals and seal as tightly as possible, with sandarac 
varnish or gutta-percha stopping. Remove and replace 

Fig. 25. — Chronic den to-alveolar abscess, with perforation of the 
root and subsequent forcing of septic matter with gutta-percha through 
the opening. Three years' duration. Radiograph. — (Author's practice.) 

this treatment in two or three days, if further attention is 

Chronic abscesses may present for emergency treatment, 

Fig. 26.— Radiograph of case, one week after operation and filling pocket 
with bismuth paste. — (Author's practice.) 

which are the result of septic matter being forced through 
a perforated root, as Fig. 25. In the treatment of this 
case, an opening for drainage was made through the 


alveolar process, to the point where the foreign substance 
protruded, this smoothed down and the pari Hushed out 
and filled with bismuth paste. The second picture, Fig. 
26, was taken one week after the operation. 

Chronic Alveolar Abscess with Fistula 

The treatment of chronic alveolar abscesses with fistula 
is one which will not generally demand an urgent emer- 
gency treatment, because the opening is present and the 
continual drain eliminates the pain. When one of these 

Fig. 27. — Chronic abscess, upper right bicuspid. — (Author's practice.) 

abscesses is seen to be draining on the outer surface of the 
face, an emergency is certainly considered to exist. 

The extraction of a tooth which has a tract opening on 
the face should be delayed until the scar is healed over. 
This may be accomplished by opening the tract inside the 
mouth, severing it between the point that is bound down 
and the exit through the alveolar process on the inside and 
turning the drain into the oral cavity. Wait until the 
outer severed portion of the tract and scar are healed and 
filled in, and then extract or treat as desired. 

The question of extracting teeth when there is an abscess 



swelling in the mouth is a doubtful one, but the writer 
believes that this should not be considered dangerous or 
wrong, as the pus in the abscess will drain readily and he 
does not believe a secondary infection occurs if the mouth 
is properly treated and cleaned. 

The aim in treating chronic alveolar abscesses with 
fistula, is to irrigate the tract from the opening in the cavity 
and the root canals, by forcing a light antiseptic bland 
solution through to the external opening and then place a 
dressing of formo-cresol solution in the canals for a day or 
two. The dental surgeon will burn this tract to its ex- 

Fig. 28. — Chronic dento-alveolar abscess, lower right, third molar. 
Radiograph. — {A uthor's practice.) 

tremity with phenosulphuric acid or phenol and fill the 
root canals. The emergency treatment is to give relief 
and prevent any complications by making a good-sized 
opening of the fistula for the drain of the pus and placing 
a pledget of cotton, rolled on a broach into the canals, and 
to endeavor to hermetically seal the cavity. 

To apply cotton in this way, hold a few fibers of cotton 
between the thumb and finger of the left hand, place the 
end of the broach in this and twist, holding the ends of 
the cotton with the same finger of the right hand. Dip it 
in the solution, place in the canal and holding the cotton 


in place with the beaks of a pair of dressing pliers on either 
side, withdraw the broach. 

This will be sufficient to meet the demands of emergency 
treatment, in chronic cases, the completion of which 
should not be delayed until a dental surgeon is available. 



When the condition present is evidently not one de- 
scribed in the chapter on dental pain and a cure cannot 
be affected by the methods given for affected teeth, we 
look to a solution of the dilemma in Neuralgia. 

Neuralgia (Nerve Pain) 

Neuralgia is a manifestation of the disorder produced 
by overexcitation of the sensory nerves or by perverted 
function. Reflex pain is a pain experienced at some point 
other than that of its origin. Neuralgia is described as 
a stinging, severe, paroxysmal pain along the course or 
part of the course of a nerve and in the area of its dis- 
tribution. Neuralgia occurs in many organs and parts 
of the body and except for those reflected from dental 
sources will be treated by the general practitioner. 

The dental operator is called upon to treat chiefly 
those which appear in the region of distribution or along 
the course of the fifth cranial nerve. These are called 
tri-facial, facial and trigeminal neuralgia. 

Marshall 1 gives a very comprehensive and complete 
idea of causes of neuralgia, in the following. 

"The conditions which are productive of neuralgia are 
many and varied and consist chiefly of diseases which 
lower the vital powers of the system, such as anemia, or 

1 "Injuries and Surgical Diseases of fhe Face, Mouth and Jaws." 





those which interfere with such functions as the circula- 
tion, respiration, digestion, assimilation, secretion and 
elimination; the presence in the system of abnormal sub- 
stances as in gout, rheumatism, diabetes, malaria, 
nephritis, chronic pyemia, syphilis and metallic poison- 
ing, local conditions which cause reflex peripheral irri- 
tation, such as diseases of the teeth, eye, ears, stomach, 
uterus and ovaries; chronic inflammation of the nerve or 
its sheath, pressure from abnormal growths, within the 
bony canal through which the nerve trunk passes, or 
pressure from tumors and localized anemia or congestion 
of nerves or nerve centers." 

Facial Neuralgia for consideration in this chapter will 
be divided into two classes: those arising from dental 

Fig. 29. — Impacted third molar. .A hidden cause of facial neuralgia. 
Radiograph. — (Author's practice.) 

sources and those arising from other than dental sources. 
In the first class we find : 

Exposed dentine around the necks of the teeth, as a 
result of abrasion, neuralgic pains may be produced by 
merely touching these surfaces with an instrument, or 
even with the finger nail. 

Pulpitis. — The pain may be referred to another part or 
area than its origin. 

Pulp nodules, or pulp stones and secondary dentine af- 
fections outnumber all other conditions as causes. 


Pericementitis. — Generally the pain is located over the 
affected tooth, yet it may not be and the pain be referred 
from this point. 

Cementosis. — This is one of the more common causes 
of facial neuralgia, because of the pressure of the growth 
against the nerve trunk or sheath. 

Deposits. — Calcic deposits on the roots of teeth. 

Impacted Teeth. — Maleruption of the lower third molars 
is the most frequent example of neuralgia from this source 
because of its anatomical relation with the inferior dental 
nerve which courses the inner part of the maxillary bone. 
Fig. 29 shows a case of Neuralgia, which ceased upon ex- 
traction. From this source, however, the pain will gen- 
erally be localized in the part. 

Burchard and Inglis state that "an equivalent of im- 
paction in which dental irritation may be the source of 
reflex neuralgia, is when the teeth are crowded or jammed 
into arches too small for their accommodation." Deaf- 
ness, suppurative otitis media, disturbances of the eye, 
temporary blindness, ovarian and uterine neuralgia, 
sciatica, pains in the knee, toes, fingers, have been traced 
to dental irritation. 

Those cases which present neuralgia from other than 
dental sources are just the opposite of the above, the pain 
definitely located or indefinitely located in a normal tooth 
referred from some other source. 

The condition in which this occurs are malaria, gout, 
syphilis, diseases of the brain, kidneys, uterus, bladder, 
disorders in pregnancy, diseases of the fifth cranial nerve, 
constipation and la-grippe. 

The paramount point in neuralgia is to find the cause 
and make the proper diagnosis. The X-ray in many 


cases, is the only method by which we may discover an 

irritating cause. 

The cause found, the treatment is to remove it and 
should it be a tooth, diagnose the condition and treatment 
for this as described in previous chapters. Do not ex- 
tract the tooth unless deemed absolutely necessary for 

Local application of drugs which act upon the sensory 
nerve ending will be used and Buckley's dental liniment 
which follows, will give excellent results. 

1$. Mentholis 1.3 gms. 

Chloroform 6.0 c.c. 

Tinct. aconite 30 . o c.c. 

Sig. — Paint over the area affected. 

Another liniment recommended by Buckley: 

T$. Mentholis 2.0 gms. 


Aetheris aa 24.00 c.c. 

Chloroformi 90 . 00 c.c. 

Sig. — Apply by vigorous rubbing or massage over the area of 
distribution of the affected nerves or along its course. 

In many cases where pain in the upper teeth is caused 
by abscessed teeth or affections of the peridental mem- 
brane, the following may be used with wonderful results, 
stopping the pain almost instantly. 1 

fy Alcoholis 

Aquae aa 30.00 c.c. 

Sig. — Use as a spray well back in the nostril of the side affected. 
Repeat as often as necessary. 

When general medicinal treatment is demanded for cor- 
rection of the constitutional disorder or alteration of treat- 

1 Buckley. 


ment necessary, the physician in charge will make these 
changes. Dentists have kept patients suffering for some 
unnecessary length of time when searching for a cause in 
the mouth when it was a general or constitutional condi- 
tion, and doctors, just the same, have treated patients for 
months without result, until the dentist removed or 
treated the offending teeth. 

While an operator is searching for a hidden cause it is 
his duty to administer hypnotic or general anodyne or 
analgesic and the prescriptions of some of the best in 
writer's experience follow: 

fy Pulveris acetanilidum comp gr. xx (1.3 gms.) 

Fiat chartulae no. iv. 
Sig. — Take one powder every hour until two or three are taken, 
if not relieved after two hours, take the remaining one or two. 

The use of phenacetine is very good in these cases, 
combined with codeine sulphate or salophen. 

1$. Acetaphenacetinae, 

Salophen aa gr. xx (1 . 3 gms.) 

Codienae sulphatis gr. i (0.6 gms.) 

Fiat chartulae no. iv. 

Sig.— Take one powder every two hours. 

Neuralgia cases will be very materially aided by the 
following prescription which is simple and efficient. 

1$. Acetanilidum gr. vii (o. 5 gms.) 

Syrupi simplex A3 ss (15.0 c.c.) 

Spiritus frumentii qs. ad. fl5 (90 c.c.) 

Sig. — Take one-half at once and the remainder in two hours. 

When these remedies will not suffice and the patient 
is in such a condition to justify the last resort, the use of 
morphine will meet the demand. Prescription should not 
be given. A dose of 1/8 gr. (0.008 gm.) may be given 


by the stomach, repeated in one-half or one hour and the 
patient given one more tablet to take at home if necessary. 
This is the conservative amount that the patient should 
take in emergency cases. The patient should be given a 
good cathartic, always; and If the conditions persist a hot 
foot bath, as advised before, will aid in the relief. 


This is an acute or chronic inflammatory process which 
includes the following features: 

A molecular necrosis of the peridental membrane (organ 
of attachment of the tooth in the socket). See Fig. 15, 
Chapter V. 

Atrophy of the alveolar walls. 

Hyperemia of the gums. 

Pus (generally at some stage) oozing out from around 
the necks of the teeth. 

Fig. 30. — Pyorrhea alveolaris. Radiograph. — (Author's practice.) 

Calcic deposits on the roots of the teeth. 
Looseness and falling out of the teeth. 

This disease is as old as man; people of all races, all 
stations and climates and time and modes of life have 
suffered from it. 

It has been studied exhaustively since the year 1746 
when Fauchard 1 published a description of it and from 

lu The American Text-book on Operative Dentistry. " 



that time to this, many able men have occupied their 
time and thoughts seeking satisfactory explanation of its 

It is the most named disease in medical science. Each 
writer having observed some particular symptom, which 
was paramount in his observation, made a title which 
conveyed his idea. 

The various titles are therefore descriptive of symp- 
toms or stages of this condition. Among the more com- 
mon titles which are or have been in use are: Pyorrhea 
alveolaris, interstitial gingivitis, Riggs disease, calcic in- 
flammation, hematogenic calcic pericementitis, gouty peri- 
cementitis. There are practically two schools regarding 
this condition, one contending a local and the other a 
general constitutional etiology. 

The local adherents cling to the following conditions as 
the causative elements; viz., subgingival deposits of calculi, 
acute inflammation of the mucous membrane, catarrhal 
conditions, germs, stomatitis, irregular teeth, malocclu- 
sion, non-occlusion and uncleanliness. 

Those who maintain the general or constitutional eti- 
ology, ascribe it to general condition of health, heredity, 
gouty diathesis, excessive lime salt secretions, meat eating, 
nervous exhaustion, scorbutus, environment and uric acid. 
Burchard describes the course of the disease as three 
stages: i. Tooth induration; 2. erosion by chemical solu- 
tion of the crowns of the teeth; 3. loss of retaining struc- 
tures of the teeth. 

The reader should consult the chart, Fig. 15, Chapter 
V, for the relative position of the structures, especially 
the alveolar sockets, the pericementum and gum tissues. 

Regarding the local causes, when there is an excess of 
salts in the blood and these are not eliminated, it is readily 
seen that such an ideal place as the free margins of the 



gums, becomes a seat of deposition. Acute inflammation 
follows and extends over the gum tissue which becomes 
turgid and spongy. It then attacks the delicate periden- 
tal membrane, which is defenseless by reason of its loca- 
tion, functions, etc. This is the most vulnerable point for 
this process and for the development of bacteria, and 
eventually of pus. 

Fig. 31. — Pyorrhea alveolaris, left central incisor, exfoliated. 

The blood-vessels pass in a plexus from the periosteum 
to the peridental membrane, and under normal conditions 
remove the calcium salts. It will readily be seen, however, 
that under the perverted condition of irritation and dis- 
turbed nutrition, this function will be hindered and the 
deposition of salts will occur instead of their removal. 
Irregular teeth, malocclusion, and non-occlusion add to 
this possibility by improper mastication landjnterrupted 
functions of the teeth, which should maintain a healthy 



condition. Inflammation will result from mechanical and 
chemical causes and as this proceeds infection is inevitable, 
as the oral cavity constantly harbors disease-producing 

The specific organisms causing the infection and the pus 
formation have not been isolated and the various forms 
found have not been sufficient to produce the disease by 
inoculation with single strains. 

Fig. 32. 

-Instruments used in emergency treatment of pyorrhea 

Talbot says, "the pathogenic conception adopted anent 
interstitial gingivitis is that the disorder is a local inflam- 
matory condition of the gums, etc." 1 

The general or constitutional causes are much discussed 
and disputed conditions. There can be no doubt that 
with a disrupted condition of health, we will have degen- 
erative conditions of the various organs and an abnormal 
amount of salts present and failure in proper elimination 
increases the probability of their effect on this disease. 

1 " Interstitial Gingivitis." 


Heredity is claimed to exert an exceptionally large in- 
fluence in some cases. 

The gouty diathesis is the form which has been the 
subject of so much discussion. 

However, when a case persists and does not yield to 
local treatment and the institution of constitutional treat- 
ment for the gout is accompanied by great improvement 
in the pyorrhea we are prone to believe that this is a cause 
of the condition under discuss on. 

The principal point, which this brings out is that of 
improper elimination and irritation of uric acid, urates 
and calcium salts, in the deposition next to the peridental 
membrane. Pierce believes this to be the local manifes- 
tation of the gouty diathesis. 1 

Talbot, however, after various and exhaustive experi- 
mentation has found such a small percentage of pyorrhea 
teeth deposits to contain uric acid and urates that he has 
come to the conclusion that "uric acid when it acts at all, 
acts as a local irritant. The general circulation, carrying 
an excess of salts as in excessive lime salt secretion, de- 
posits it through the process spoken of above, when it 
becomes a local irritant. 

Nervous exhaustion is considered for the effects that 
follow in the structure and the reduction in tone of the 
immediate organs of supply. Uric acid is given as a result 
in gouty pericementitis. Its presence and' irritation is one 
of the main points, in the class considered to be of con- 
stitutional etiology. 

It is the aim of the writer to present to the reader 
only an outline of the disease, as it will be presented for 
diagnosis and enough of the ideas of the energetic men 
who have contributed so much toward clearing up the 
baffling conditions, to make it intelligently understood. 

1 " American Text-book of Operative Dentistry." 



There is not space in this work to deal otherwise with this 

The diagnosis of pyorrhea alveolaris will be by sight 
and touch. The gums are generally red, turgid and con- 
gested. Pressure will bring a show of pus. Pain in the 
alveolar sockets is not usually experienced. This point 
is the unfortunate part in the disease, because an unob- 

Fig. 33. — Pyorrhea alveolaris, showing instrument, angle and fingers 
used in scaling tartar. 

serving patient will not know of its existence. Hard, 
black, brown or" yellow calculus will be found attached to 
the sides of the roots and the gum tissue will at times cover 
this. A pus-pocket may exist along the side of the root 
unobserved, except that the tract or the seepage will be 
noticed at the gum margins. An offensive odor attends 
the progress of the disease, especially in unhygienic 
mouths. The diagnosis can be confounded with a few 


other conditions, such as gingivitis, stomatitis, mercurial 
ptyalism, impacted teeth, or effects of ill-fitting dentures. 
It makes its appearance generally between thirty-five 
and fifty years of age, with symptoms practically the 
same as acute non-septic pericementitis. The color of the 
gums is deep red or purple, over the ends of the roots of 
the teeth affected. Constitutional conditions which may 
cause pyorrhea and upon which diagnostic symptoms may 
depend will be gleaned from the history. 


The treatment of pyorrhea alveolaris in emergency cases 
is to give relief from pain and save teeth. The teeth fre- 
quently are very loose and appear to have little attach- 
ment, but after the first treatment and institution of 
prophylaxis, they will tighten to a surprising amount. 
Extraction in chronic cases is practised where the absorp- 
tion of the peridental membrane and process has gone 
beyond repair, but in the first-aid treatment that pro- 
cedure should seldom be resorted to. Acute pains of the 
abscess variety will cause the patient to seek relief; and 
in this, temporary treatment will do a great deal more than 
might be supposed. The patient will present with severe 
pains around the roots of the affected teeth. The gums 
will be purplish and swollen; pressure on the teeth will 
respond as in abscesses. The hyperemia and the pain 
of the gums will be a diagnostic sign. There will generally 
be deposit on the roots under the gums; and the teeth 
may be somewhat loose. It is our duty to relieve this 
patient without delay. There is no satisfaction in telling 
him that he has pyorrhea alveolaris and cannot be cured; 
and we cannot be barbarous enough to extract the teeth 
affected, especially at this sitting. 



Wash the mouth with one of the solutions given before 
and use a syringe to Hush out the spaces as previously 
stated, the solutions should be hot. As in all diseases 
the first rational step is to remove the eause. 

If the condition has a constitutional basis, it will be 
reduced through systemic channels. The following treat- 
ment will be necessary in this as it will in the local con- 
dition, as the local effect must be repaired. 

Fig. 34. — Pyorrhea alveolaris instrumentation. 

Fig. 32 shows four pyorrhea instruments or files, which 
the writer believes will be sufficient to treat emergency 
cases. The pyorrhea specialist uses from twelve to one 
hundred instruments for the treatment of this condition; 
including every angle and edge to suit conditions and 
manner of operation in removal of tartar. These four 


instruments will be used as shown in Figs. 33 and 34, 
to enter under the free margins of the gums and file down 
or cut away the hard deposits. In doing this care must 
be taken to follow the sides of the teeth and enter through 
the tracts leading to the pockets. 

Remove all the hard deposits found and flush out the 
edges of the pockets with an ordinary mouth syringe and 
a warm solution. The gums will bleed freely and will 
appear to be very badly injured, but when these pockets 
have been scaled and the gums massaged the relief given 
by the hemorrhage will be apparent. 

The practice of using orange wood sticks or any other 
methods of placing strong acids in these sockets in emer- 
gency treatment or permanent treatment is condemned. 
A surgeon does not apply acids to a fractured joint as a 
treatment under any circumstances, septic or aseptic, 
since necrosis would result. The same reasoning applies 
in this condition. We want to make tissue grow, not 
destroy it, and nature should be given an unhampered 
opportunity. We should treat these cases with the idea 
of getting rid of the tartar, the pus and the excess blood 
and then use the following remedy which will prevent the 
germs of the oral cavity from entering and adding to the 

Hartzell 1 has given us the remedy of painting the gum 
margins with tincture of iodine and cresote and following 
this with glycerite of tannin, which will be seen to be a 
powerful astringent and anodyne, sealing the edges of 
the gums around the necks of the teeth. 

Place cotton rolls on the outside of the gums on the 
upper jaw, and on either side on the lower. Being posi- 
tive that the pus and tartar have been removed, take a 
small pledget of cotton, saturated in the tincture of iodine 

1 "Dental Cosmos," 1913, p. 1094. 


and creosote, and paint around the gum margins and 
necks of the teeth. Take another pledget and sear over 
these with the glycerite of tannin. This should be left 
for twenty-four hours and the patient instructed not to 
brush his teeth. However, the patient should be in- 
structed to use the toothbrush the next day. A softer 
brush than medium, should never be used, the hard bristles 
should usually be advised. Brushing the gums with soft 
brushes does not give them the exercise and friction neces- 
sary to reduce them, when soft and spongy, to a hard 
healthy condition. 

The patient should be instructed to massage the gums 
with the finger, which is a difficult process in some parts 
of the mouth. The writer advises that the patient hold 
a small amount of a warm astringent solution in the 
mouth and with the cotton rolls shown in Fig. 19 on the 
finger, go all around the gums. The patient should be 
instructed to brush his teeth as directed in Chapter II. 

The cause being considered constitutional and the con- 
dition in the mouth as a local manifestation, the above 
treatment should be applied and the patient given a good 
cathartic, advised to drink a large quantity of water and 
abstain from the eating of foods which carry much lime 

Constitutional treatment will be directed by the 



The word fracture means the breaking of a bone or 

Stimson gives the following classification of the various 
kinds of fractures, with which are given subdivisions under 
each head. 

i. Incomplete Fractures. 

2. Complete Fractures. 

3. Multiple Fractures. 

4. Compound Fractures. 

5. Gunshot Fractures. 

The causes of the fractures of the bones of the face are 
many and varied. The superior maxillary bone is not 
prone to fracture because of its position and protection 
by the various processes. Fractures of the bones are 
always produced by direct violence and present variance 
according to their etiology. The various processes are 
fractured with violent blows, a blow on the cheek may 
break the malar bone and fracture the anterior border of 
the antrum, as also a fractured nose may include the nasal 
process. The alveolar process may be broken up exten- 
sively by a blow on the mouth, or in the extraction of 
teeth such a blow may separate the palatal process from 
the body of the bone. Stimson quotes a case of his prac- 
tice, in which the face was crushed in an elevator, ... . 
" the nasal bones were separated from the frontal along the 
suture line, the right malar and zygoma broken; and both 
superior maxillae displaced downward and backward and 


separated from each other along the median line of the 
hard palate." In one case the bones of the face were so 
movable that they moved up and down when the patient 
swallowed, as if they were only restrained by the skin. 
In order to produce these conditions, the extreme violence 
necessary and the extent of the injury would seem neces- 
sarily to involve the cranium, but the reason given for 
the cranium's immunity, is that the direction of the force 
is always more or less parallel to the surface of the cranium. 

Comminuted (splintered fragments of bone) fractures 
often occur in gunshot wounds and injuries of all descrip- 
tions. The diagnosis of this fracture is comparatively 
easy and can be made without difficulty because the mouth 
and external surface afford easy access for manipulation 
with the fingers. It presents an irregular outline, displace- 
ment, mobility and crepitus. 

These cases are treated by placing the parts in proper 
relation and retaining them. The method advised in this 
chapter is that of fixation of the upper to the lower jaw 
by the process of wiring the teeth. 

In the fracture of the alveolar process, place the frag- 
ments of bone in proper position and the teeth in their 
sockets and fix by wiring or apply splints made of gutta- 
percha over the cutting edges of the teeth and parts. 

Loose teeth should be replaced in the sockets, no matter 
how loose they appear to be in the fracture, as they will 
eventually tighten in place. Extraction endangers be- 
cause of possible removal of the part or parts of bone. 

Fractures of the Inferior Maxilla 

This fracture is more common and important from the 
dental operator's standpoint as injuries of the upper face 
will usually be dealt with by the surgeon. 


The technical knowledge of the relationship of the jaws 
and the occlusion of the teeth, together with the manipu- 
lation of these parts brings the operation of the inferior 
maxilla under the dentist's care. 

Fractures of this bone generally occur in patients be- 
tween the ages of twenty and thirty. It is the most com- 
monly fractured bone of the face by reason of its location 
and function. Its fracture is much more common in men 
than in women. 

Incomplete fractures of the mandible are those which 
only include the alveolar process or some part of the 
border of the bone. Complete fractures are those in 
which the fracture extends through the entire bone, di- 
vided or classified by the direction of the fracture as 
oblique, longitudinal, transverse, etc., and comminuted. 

Compound fractures are those in which the membrane 
covering the bone is broken or cut. They present an open 

Gunshot fractures are as the name implies. 

In the extraction of teeth, in blows, falls or any external 
violence against the teeth or face, the alveolar process is 
very liable to be broken, as is also a part of the border. 

The writer has recently had a case of fracture of the 
mandible, in which the external plate of the alveolar pro- 
cess was fractured from the right to the left cuspid tooth 
with a small triangular fragment broken from the body 
of the bone. His history showed fracture seven years 
before. There had been continual drain from the lower 
central incisors, which moreoyer were affected with pyor- 
rhea alveolaris. The displaced alveolar plate became 
firm, but the fragment of the body of the bone was re- 
moved because of necrosis, Figs. 37 and 38, and the two 
central incisors were later extracted. 

Complete fractures occur more frequently in the anterior 


portion of the bone. Stimson states thai "of 75 single 
ones of these, the fractures occupied the median line in 25, 
the region of the anterior in 22, that of the back teeth in 15, 
behind the teeth in 8 and in the condyloid process in 5." 

In the writer's experience the majority of cases have 
been multiple fractures, mostly double. This condition 
has been obtained probably by reason of the difficulties in 
these cases, the necessity of dental technic, affording the 
opportunity in consultation. The fracture of the body 
of the bone generally has a vertical direction; in the ramus, 
it is usually oblique. 

The fractures through the symphysis or the vicinity of 
the anterior teeth do not show great displacement, part 
of the lines of occlusion of the teeth being correct, however, 
a slight separation of the teeth in the respective fragments 
will generally be noted. Posterior to the cuspid teeth, 
the fracture will be more easily noted, the abnormal occlu- 
sion being prominent because of the action of the masseter 
and pterygoid muscles. 

In a case in the writer's practice a simple fracture 
through the symphysis was not noticed for three weeks 
after the accident, when inability to masticate brought the 
patient for treatment. In shooting a rifle, the rebound 
caused the stock to come forcibly in contact with the 
point of the chin and a vertical fracture resulted. 

Another case of compound fracture presented. A pa- 
tient while under the influence of alcohol was struck on 
the point of the chin, from the right side and neglected 
treatment for several days. Examination showed a frac- 
ture through the body of the bone at the left of the lower 
left lateral incisor, one through the socket of the right 
cuspid and one anterior to the second molar, the first 
molar being absent. The mouth was foul and infected, 
the patient at the time had various venereal diseases. The 


anterior fragment was drawn directly back into the mouth, 
the teeth pointing almost toward the tongue, the other 
fragment was drawn in also, the anterior part overlapping 
the former, the posterior portion was in good position. 

In another case, the patient received a blow on the point 
of the chin with a stool, with fracture through the sym- 
physis, and between the second bicuspid and first molar. 
Patient had failed to report and infection followed, the 
jaw had been lanced on the outer surface and drained. 
The parts were not in very bad alignment and were pain- 
ful only upon movement. A large amount of necrosis fol- 
lowed in this case, with resultant removal of sequestra. 

Many cases of abscess opening into the mouth are 
associated with small fragments of bone, these are exfolia- 
tions or splinters and must be removed. The diagnosis of 
fractures of the inferior maxilla is comparatively simple, 
as the observation of the parts and manipulations will show 
abnormal mobility, crepitus, displacement and pain. 


There are many and varied means of treating these 
cases; and as is true of all conditions, many which answer, 
but are npt sufficient. The treatment of the mouth should 
be taken first and the hot solution of one of the mouth 
washes used to flush it out. The use of a swab of cotton 
to go gently over all the teeth and get the field as clean as 
possible makes the patient grateful, the working in the 
cavity more pleasant and safer. The class and extent of 
the fracture should be determined and the method of 
retaining selected. 

In edentulous jaws, where there is no occlusion of the 
teeth to determine the proper placing of the parts; the use 
of the four-tailed bandage and gutta-percha splints will be 
found the best method of retention. 



A wax mold should be made of the upper and lower jaw 
and a wax bite secured, plaster casts made and mounted 
on an articulator, over which warm gutta-percha should 
be molded, cooled and trimmed to fit the case. Insert in 
position and apply the bandage using a pad covered by 

Fig. 35. — Bandaging the jaws together (modified-Barton's). Front view. 

a piece of wet cardboard under the chin, Figs. 35 and 

The method of wiring the teeth, in the author's opinion, 
presents the quickest and easiest as well as the most 
sanitary and surest method of proper retention. The 
parts of the fracture are brought directly before the eye 



of the operator, during the entire operation and treatment. 
In complicated cases, it serves the purpose far better than 
splints, because of ability to reduce gradually or separate 
the jaws without disturbing the union. There is no 

Fig. 36. — Rear view of Fig. 35. 

method whereby control from mobility can be secured as 
with the wiring process. 

In the first case cited an X-ray plate was made, Fig. 
37, which showed there was not a complete fracture, the 
lower teeth were tied together in the sockets and an align- 
ment wire placed over the entire lower set, by inter-lacing 
with twenty gauge wire. The jaws were fastened together 



for ten days. The wound was dressed and packed with 
gauze, dipped in iodoform, orthoform and campho-phc- 
nique paste. The case was painful and the drain of the 
pus persisted. Removal of the two central incisors and 
incision was made over the fragment of bone which was 
removed and the case was practically cured, Fig. 38. 

Robert T. Oliver 1 has given a method of wiring a 
slightly transverse fracture through the socket distally 

Fig. 37. — Fracture. Case 
1 — Maxillary process, in- 
volving border of body of 
maxillary bone. Radio- 
graph. — (Author's practice.) 

Fig. 38. — Case 1, one month after 
removal of sequestra and teeth, process 
firmly re-attached. Radiograph. — 
(Author's practice.) 

of the first bicuspid and mental foramen. He uses copper 
wire, annealed, about 4 inches long, inserts one end through 
the space between the lateral and canine teeth, burnishes 
lingually to the canine, pulls through half . the length, 
brings it back through between the canine and bicuspid, 
then the other end is inserted between the canine and bi- 
cuspid, burnished to the lingual side of the first and second 
bicuspids, carried back across the fracture, inserted from 
1 "Dental Cosmos," Sept., 191 1. 

9 6 


Fig. 39. — Dr. O. T. Oliver's method of wiring across the fracture. Pencil 
mark representing fracture. 

Fig. 40.— Method of lacing teeth and wiring across the fracture, wires 
loosely applied for photographic clearness.] 



within through the space between the first molar and sec- 
ond bicuspid, brought forward taut and the ends twisted. 

Fig. 39- 

Fig. 40 shows the author's method of reducing by lacing 
the teeth with a wire about 6 inches long and bringing 
the cross forward between each tooth except the two 
adjoining teeth on either side of the fracture, where the 
wire extends along each side of the two approximating 

Fig. 41. — Wires in place on the teeth previous to reduction and twisting. 

teeth, then to cross again, the cuspid encircled and the 
ends of the wires twisted at the cuspid tooth. 

This process is used in fractured bones to draw together 
and retain the parts. The teeth of the full upper jaw are 
wired as follows: Small wires about 2 inches long are 
placed tightly around the gingival margins under the gums 
and twisted in the same direction, preferably to the right, 
on each tooth. The number of the teeth wired in this 



manner will be determined by the amount of fixation 
deemed necessary. The lower teeth opposite the uppers 
are all wired to correspond with the other and the wires 
turned forward in the mouth. Fig. 41. 

The reducing wire is twisted until the parts appear to 
be together in contact and then the jaws are closed and 
held by an assistant. Then on the side which is not frac- 



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Fig. 42. — Wires twisted showing free end, before bending into spaces 
between teeth. 

tured, twist the wires of opposing teeth until the cusps 
are almost in proper contact. Fig. 42 ; the fractured side 
is then drawn up in the same manner as near as possible. 
If the parts are swollen or too painful absolute contact 
will be difficult and in this method it is unnecessary, 
since the parts can be moved or reduced gradually for 
seven days. 

Place a bandage over the head as shown in Fig. 35, 
to counteract the muscular contraction which tends to 



break the wires. A gauze pack covered by a piece of wet 
cardboard is molded over the skin and this is covered by 
the bandage, which need only be worn for a few days. 

Traction on these fragments is nearly always desired 
and the wiring process presents full possibilities for the 
action required. This is the great advantage over all 

Fig. 42a. — Twisted ends of wires turned in and covered with gutta- 
percha to protect the lips. 

other methods. Dr. Oliver 1 describes an original method 
of constructing an anchor loop for the alignment wire, 
of either upper or lowers, by twisting a copper wire around 
a mandrel thus making a loop, which can be tacked with 
hard solder and placed at the point desired for application 
of the traction wire. 

There is no necessity for extracting any teeth in this 
method for feeding purposes as the patient under any 

1 "Dental Cosmos," 191 1. 


circumstances is required to subsist on liquid diet and 
the entrance of this has sufficient space around the pos- 
terior teeth. The patient may also be fed by a tube passed 
through the nostril. 

The wires are cut short and covered with wax or gutta- 
percha, which is changed daily. Fig. 42a. They are 
brushed with a small brush, syringed out and a good 
mouth wash advised. Hydrogen peroxide is valuable in 
the wash for cleaning around the wires. 

In cases where union is delayed, with the lower jaw 
wired to the upper and the alignment wires in place, it 
is a simple matter to loosen the jaws by untwisting the 
wires; if it is necessary to incise and scrape the edges of 
the fracture or remove sequestra or splinters. Where the 
union of the fragments demands that the wire be placed 
through the bone, the process is simple Make an incision, 
through the soft tissue in a line along the body of the bone, 
separate the soft parts from the bone then with a spear 
point or cone-shaped drill, make a hole through the proc- 
ess between the teeth on either side of the fracture, being 
careful to have plenty of structure between the edges of the 
fracture and the hole. Place a twenty gauge silver wire 
through the hole, with the free ends on the outside, twist 
until apposition is secured. Leave this twisted part of 
the wire about an inch long and if necessary stitch the 
wound on either side, leaving the twisted ends of the wire 
exposed. When the union is accomplished, clip the pos- 
terior portion of the wire beneath the twisted part and 
carefully remove it by holding the twisted portion in a 
pair of pliers and pulling forward along the line of the 

Cases should heal in from three to six weeks and with- 
out deformity or improper occlusion, such as often results 
where the teeth are hidden from view by the use of splints. 

fractures and dislocations of the jaws ioi 

Dislocation of Lower Jaw 

There is nothing so distressing to the patient as a dis- 
location of the lower jaw. A study of the anatomy of the 
part will show the comparative ease with which the dis- 
location occurs. It occurs in from 3 to 6 per cent, of all 










mm j 





' 4 




{ eminence 

I Synovial 
Glenoid fossa 

Condyle of 



Fig. 43. — Temporo maxillary articulation. 

dislocations. Fig. 43 shows the joint in proper relation- 
ship with the parts noted. 

The glenoid fossa is the socket which, lined with a pad, 
the synovial membrane, receives the condyle of the in- 


ferior maxilla. The articular eminence forms the anterior 
border of the fossa. In dislocations, the condyle comes 
forward over this eminence. 

Backward and internal or external dislocations are rare, 
without other complications. The condyle is attached by 

Fig. 44. — Method of reducing dislocated maxilla with use of pencil 
between the teeth. 

liagments, the capsular, internal and external lateral, 
which are stretched during the dislocation. 

Relaxation of these ligaments and contraction of the 
muscles, violence in the mouth, laughing, shouting, yawn- 
ing, vomiting and dental extractions, are the most com- 
mon causes of dislocation, one or both sides may be 

The symptoms of the condition include a protrusion of 


the lower teeth, a depression in front of the car and ina- 
bility of the patient to manipulate the jaw. If unilateral, 
the chin will point to the opposite side. 

The treatment is the reduction of the condition whieh 
ordinarily in recent cases is not difficult. 

Fig. 44 illustrates one method of reduction, after placing 
a pencil, a small stick or cork between the molar teeth, 
the operator standing at the patient's back, by upward 
pressure on the chin forces the condyle down to a level 
with the articular eminence, a slight pull aided by the 
action of the muscles, will then be sufficient to snap the 
jaw into place. 

The thumbs of the operator may be bandaged and placed 
in the mouth, operator in front of patient and pressure 
made on the molar teeth with an upward force applied 
under the chin and relocation gained in this manner. 

The use of the jaw should be limited for a few days; in 
severe cases a bandage, as shown above, applied for such 
time as the operator deems necessary. 


Throughout this book, appeal has been made to save 
the teeth. When extraction has been decided upon it 
will be assumed that all the resources of treatment have 
been exhausted Many writers have made various rules 
for dentists to follow in deciding to extract, but with all 
respect to them, the judgment of the operator in each case 
must decide. 

It is impossible to pull certain teeth, which with proper 
manipulation will yield with comparative ease. The pro- 
cedure described by the expression that "the patient was 
dragged all over the office or that the operator pulled 
with all his strength, etc.," is barbarous and absolutely 
unnecessary. The erroneous idea given by the words 
"pulling or drawing teeth' 7 will be eliminated and replaced 
by the proper words "extracting or removing teeth." 

The nervous condition of the patient tends to influence 
the operator to hurry and there is no operation which 
demands deliberate and concise actions as does extracting. 

Improper methods and ill-applied force cause so many 
accidents in extraction of teeth that exact knowledge of 
the structures and their relations is necessary. The acci- 
dents include fracturing the jaw or alveolar process, re- 
moving parts of the floor of the maxillary sinus, fracturing 
of other teeth, extraction of the wrong or more than one 
tooth and in injuries to the tongue and soft tissues. The 
points given under the extraction of each tooth, will aid 
in rational extraction. 



Failures, accidents and complications occur in extrac- 
tions and these must be guarded against by a study of the 
parts, knowledge of the eruption of teeth, care and proper 
manipulation of instruments and consideration of oral 
sepsis, during and after operation. 

Failures in removing all of the root or roots of teeth 
occur for various reasons. Some teeth present a ball at 
the end of the root. This will give great difficulty and 
probably be left in the jaw, the root breaking above the 
ball. Other roots may break in the socket; and while the 
practice is not correct, operators, who are not thoroughly 
experienced will do well to restrain from too strenuous 
efforts to get these roots. 

In the extraction of the upper molars and bicuspids the 
roots impinge closely upon and sometimes enter the cavity 
of the maxillary sinus. Faulty or forceful extraction is 
liable to bring out a large portion of the bone which forms 
the floor of this cavity, and serious complications result. 

The extraction of the deciduous teeth or roots must be 
accompanied with caution, as to the distance the forcep 
beak is forced under the process since there is liability of 
injury to permanent teeth, which lie underneath. 

In grasping a tooth through the alveolar process, in 
cases of roots deeply imbedded in the tissue, to force it 
from the socket by pressure on either side of the alveolar 
plate, application of too much force is liable to carry away 
a large quantity of the process. The reverse of this, the 
introduction of the beaks of the forceps, which are too 
thick, between the root and process is liable to sever or 
spread the process to the extent of fracture. 

The opposite teeth are easily fractured by slipping for- 
ceps and a guard should be made by a finger of the oppo- 
site hand. There is danger of the tooth falling into the 
throat, after removal from the socket, in withdrawing it 


from the mouth, especially is this true of the wisdom 
teeth, if extracted with forceps which have too large a 
bow in the beaks. 

The patient should always be placed in such a position 
that the operator may have full view of the tooth, or that 

Fig. 45. — Lancing gums over erupting third molar, showing triangular 
incision, outer surface. 

the fingers of the left hand may guard the beaks from the 
danger of including another tooth. 

Precaution from infection during the operation should 
be taken. Large exposed wounds or sockets should be 
kept clean with a hot solution of one of the antiseptic 
mouth washes previously mentioned, until granulation 
begins and the socket closes. The treatment of infected 
sockets will be taken up later. 



The practice of lancing the gums, in extraction of teeth 
with crowns and a free gum margin, is not always advised; 
but with roots, it is seldom that the slitting of the gum is 
not necessary. 

To lance this tissue use a sharp, straight or curved 
lancet; and free the tissue from the root on either side for 
the reception of the beaks of the forceps, or make a short 


Fig. 46. — Lancing gums over erupting third molar, showing triangular 
incision, inner surface. 

incision on the inner and outer gum surface parallel to 
the root and through to the bony process. 

In the lower wisdom teeth, if extraction is contemplated, 
or eruption to be aided, cross lancing is not advised, but 
a triangular piece of the gum should be removed. Make 
an incision from a high posterior point over the tooth to- 
ward the outer surface. Fig. 45 and then one on the inner 
as shown in Fig. 46 and then by a cross incision, remove 



the gum tissue thus severed. If this tooth is to be ex- 
tracted it will be a simple matter to grasp the tooth with 
the forceps. 

In preparing to extract a tooth, take the mouth mirror 
and with an explorer go all around the tooth and notice 
its attachment, its roots, and the angle as which it sets in 

Fig. 47. — Elevators to be used in the extraction of roots. 

the process. The writer then paints the tooth and sur- 
rounding tissue with tincture of iodine. Many times in- 
fection which lies in and around the tooth is carried down 
into the sockets. This procedure seems to prevent this, 
the iodine exerting the antiseptic action. 

The choice of the forceps should be made with considera- 


tion of four points, viz., 1. The shape and the size of the 
beak should fit the tooth or root and not obstruct the 
view of the tooth. 2. The handles should fit the hand of 
the operator when the beaks are separated to the point 
necessary to grasp the tooth and the handles should be 
serrated to aid the grip so that the sensitiveness of the 
hand to resistance in extraction will not be destroyed. 3. 
They should be of proper material (good steel) and not 
bend or break under stress. 4. They should be cleaned 
and sterilized before using. 

The large number of forceps on the market represents 
many particular kinds devised by individuals and some 
of these cannot be used by most operators. Doubt is 
felt as to whether they can be used with success by the 
men who devised them. 

The extraction of teeth by elevators is at times very 
satisfactory, it is a simple matter to place the beak down 
into the socket and by a prying movement force the root 
from the socket. The extraction of each individual tooth 
and its root will be taken up, in detail. 

The Procedure of Extracting 

The knack or art of extracting does not depend upon 
the strength of the operator, but lies in the sensitiveness 
of the hand to the giving away of attachment and the 
resistance of the tooth. This should guide the operator in 
applying force of withdrawal, as the teeth should be 
loosened before removal is begun. 

The writer places the patient as low as possible in the 
dental chair and attempts to keep the head as near a 
line of his waist as possible. This will keep the elbow 
down and afford a sort of fulcrum. If the elbow is above 
the line of control of the shoulder muscles, difficulty will 



generally be experienced. The patient is tipped back for 
all of the upper teeth and sits upright for all of the lower. 
The protection of the lips must be made by the fingers of 
the left hand. 

Fig. 48. — Position of hand and thumb gripping forceps for upper anterior 
teeth and roots. 

Extraction or the Upper Teeth 
Examine all teeth surrounding with a mirror. 

Central Incisors 

One large, strong, round, conical root; select forceps 
shown in Fig. 48, or similar pair. 

Take position as shown in Figs. 50 or 51. 



Place inner beak of forceps well up on lingual surface at 
edge of enamel, genii)' close the forceps over the outer sur- 
face and with a rotary movement, force the beaks under 
the gums until they touch the alveolar process Fig 52. 

Rotate and twist; using an " in-and-out "motion if resist- 
ance so demands; when loosened withdraw straight from 

Fie. 49. — Position of hand gripping forceps, thumb placed between 
handles to prevent crushing tooth. 

the socket. Press alveolar walls together with the thumb 
and linger. 

The extraction of the root of this tooth is practically the 
same procedure, except where it is broken off far under 
the process and it cannot be gripped with the forceps, 
then after lancing the gums parallel to the root, place the 



beaks of a root forceps as shown in Fig. 53 and pressure 
will generally spring the tooth from the socket. 

The Lateral Incisor 

One small, flattened root, curved somewhat toward the 

Use same forceps as for central. 

Fig. 50. — Position for operator. Extraction of teeth — upper left side 

of jaw. 

Take the same position. 

Apply the forceps the same as with the central. 

Place forceps on the tooth in the same manner. 

Use an " in-and-out motion " and if resistance is felt, 


I U 

Fig. 51. — Position of operator. Extraction of teeth — upper right side 

of jaw. 

Fig. 52. — Extraction of upper incisor teeth. 


use a rotary movement. Any movement may be used 
which the operator feels, in his hand, is breaking the 

Withdraw the tooth, when loosened, directly from the 
socket. Press alveolar walls, with the thumb and finger. 

Fig. 53. — The extraction of the upper anterior roots. Forceps in 
position to compress or cut through the alveolar process. 

The extraction of the lateral root is practically the same 
as that of the central incisor. 

The Cuspid or Canine 
{Called the Eye Tooth) 

One long, slightly flattened round root. 

Sets in the jaw more firmly than any other tooth. Last 
to erupt, therefore frequently malposed and the root 
wedged between the lateral and bicuspid. 



Roots project at times into the maxillary sinus. 

Use forceps shown in Fig. 48 or one with a straight 

Apply forceps on the tooth in the same manner as 
shown in Fig. 54. 

This tooth is at times twisted and pressure on the for- 
ceps should be applied "in and out," in a line of its 

Fig. 54. — Forceps in position. Extraction upper cuspid. 

greatest thickness, a rotating movement will be used to 
advantage and sometimes a backward motion. The sen- 
sitiveness of the hand will show the line of least resist- 
ance . When loosened it is usually easily removed. Press 
alveolar walls together with thumb and finger. 

The extraction of the root is practically the same as 
the tooth, except where it is broken under the process. 
In this case, lance the gum to the bone on the labial side, 
observe the direction of the root, and if wedged remove a 
small portion of the process with elevator No. 1, Fig. 



47, place beak of forceps well up on the inner side and 
remove straight out from the labial process. 

First and Second Bicuspids 

The first bicuspid: Usually two small, divergent roots 
which are generally round. 

Use forceps shown in Fig. 55, and apply in same man- 
ner as incisors. 

Take position as shown in Fig. 50 or 51. 


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Fig. 55. — Extraction of upper left bicuspids, showing guard of finger 
behind forceps. 

Use an " in-and-out " motion. The tooth will loosen 
in many cases but not be easily removed because of the 
bony process within the bifurcation. Carrying the tooth 
outward will generally bring the tooth away, the outer 
alveolar process being thinner than the inner. In case 
difficulty occurs, these roots can be separated and removed 
with the root forceps, shown in Fig. 53. 


The second bicuspid has a single slightly flattened root. 
Occasionally there are two. 

The application of the forceps and extraction is prac- 
tically the same as the first bicuspid. 

The roots of these teeth will be removed with the forceps 
shown in Fig. 53. If one root of a double-rooted tooth 
remains, place one beak of the forceps in the socket and 
the other under the gums, and process. Its extraction 
will be simple. 

The First and Second Molars 

These upper molars are very similar and the procedure 
in one the same as in the other, they both have three roots, 
one palatal (inside) and two buccal (outside). Consult 
Fig. 14. They vary in degrees of separation and there 
is no set rule for their extraction. 

These teeth are the most commonly broken by inex- 
perienced operators, by cutting the crowns with too much 
pressure on the forceps. Forceps Fig. 56 has grooves 
divided by a point on the outer beak, which fits between 
the buccal roots. A right and left pair of this forceps 
must be used. 

Apply forceps well down under the gums, and with <the 
thumb pressed between the handles to prevent too great a 
pressure on the beaks, force with an inward motion. This 
places the inner beak well up on the single root and then 
force outward gripping tightly. When the beak is felt to 
go between the roots, proceed with a slow, steady, inward 
movement, the outer roots will give. The inner root will 
follow generally in the reverse outward motion. 

Rocking the tooth will loosen the attachment. Rota- 
lion is impossible. 

Withdraw outward. 



The roots of these teeth to be removed when the crown 
is missing should be taken one at a time. Use root for- 
ceps shown in Fig. 53. Take the anterior root first, with 
a direct in-and-out motion. The other buccal root, with 
rotary motion, and lastly the palatal root, the outer beak 
being placed in one of the empty sockets, apply pressure 
upward and then remove in the line of the direction of 
the root, outward and downward. 

Fig. 56. — Extraction of upper left molars. 

The Third Molar 
(Wisdom Tooth) 

The number of roots varies from one to seven. The 
majority have one and three. The upper third molar is 
the easiest tooth extracted. 

The bayonet-shaped forceps, Fig. 48, in the writer's ex- 


II 9 

perience is the best shape to be used, although the forceps 
shown in Fig. 57 is larger and heavier and in inexperi- 
enced hands may prove more satisfactory. Fake position 
as with other teeth on the proper side, Fig. 50 or Fig. 51. 
Place outer beak over the buccal surface of the tooth 
and bring inner beak to place, force the forceps up in the 
line which it now stands. Grip the tooth and turn upward 

Fig. 57. — Extraction of upper left third molar wisdom tooth, showing 
fingers guarding against dropping the tooth down the patient's throat. 

and outward; an inward motion does no good until the 
tooth is loosened in the socket. 

The fingers may be placed inside the mouth as shown 
in Fig. 57, just before removal to prevent the tooth from 
slipping through the forceps into the throat. 

The inner alveolar plate is very thick and the outer one 
thin, so the in-and-out motion is not used. 



The Lower Teeth 

The lower teeth are more difficult to extract than the 
upper ones because of the inability to see them as well. 

The cheeks and the lips are more obstructive and the 
tongue, is generally in the way. Care must always be 

Fig. 58. — Position of operator. Extracting teeth, lower central incisors. 
Protection of lips with fingers of left hand. 

taken not to tear the gums or catch the tongue in the 

The Central and Lateral Incisors and Canine 

These teeth have all straight compressed roots except 
the cuspid which is sometimes wavy and rounded. Their 
extraction will be considered in one description. 



Position as shown in V\£. 58. 

Carry the lips away with the left hand and apply the 

Fig. 59. — Forceps in position. Extraction lower incisor. 

Fig. 60. — Position of hand and thumb gripping forceps for lower anterior 
teeth and lower roots. 

forceps as shown in Fig. 59, press firmly down under the 
gums and with an inward and outward motion rock the 



tooth and when loosened withdraw. Care must be taken 
in withdrawing these teeth, not to let the forceps strike 
the upper teeth when the tooth comes out. 

The canine will give some trouble, as this root is much 
longer than the others and being rounded a rotary motion 
will be added to the above process. 

Fig. 6 i. — Position of operator. Extraction of teeth — lower left side of 


The roots of these teeth will seldom be presented for 
extraction, neither will the teeth except when loosened by 
pyorrhea alveolaris. 

The Lower First and Second Bicuspids 

The roots of the first and second bicuspids are generally 
the same. The first, however, has two canals, but the 
roots are generally not separated. 



Fig. 62. — Position of operator. Extraction of teeth — lower right side. 



Fig. 63. — Forceps in position. Extraction lower cuspid. 



They are compressed and round and slightly flattened. 

The posi$ion will be taken as shown in Fig. 61 or 62. 

The forceps may be used as shown in Fig. 58 or 64, and 
applied as shown in Fig. 64. 

Press down well and rock the tooth with a direct inward 
and outward motion, until the tooth is loosened and then 

Fig. 64. — Extraction of lower left bicuspids. 

withdraw it. These teeth will generally give little trouble 
if the forceps are properly applied. 

Press the alveolar process together with the finger and 

Their roots are somewhat difficult to extract if broken 
off under the process. 

Lance to the bone on either side and with the root for- 
ceps shown in Fig. 60, squeeze through the process and 
the tooth can be withdrawn. 


I 2< 

The Lower First Molar 

Two long roots, generally curved backward, slightly. 
Consult Fig. 14, Chapter V. One anterior and one pos- 
terior root, which are separated about the center of the 
tooth. Molar forceps are made with points and grooves 
on the beaks to fit in this space, between the roots, Fig. 
65. Fig. 66 shows a "hornbeak" forceps in proper posi- 

Fig. 65.— Extraction of the lower left first molar. 

tion, the points of the beaks here are received in the 
separation of the roots, Fig. 67. 

The forceps are pressed well down until the beaks go 
home around the roots. The tooth is rocked in and out 
and will generally give way and then may be removed. 
Sometimes, however, it is necessary to keep up this motion 
while withdrawing from the socket. 



Fig. 66. — Extraction of lower molars with a hornbeak forceps. 

Fig. 67.— Position of hand, gripping hornbeak forceps for lower molar, 
side view of thumb between handles to prevent crushing. 



Fig. 68. — The elevator in position for the extraction of roots. 

Fig. 69. — Extraction of lower right second molar. 



The roots of this tooth are more prone to break than 
others and will be removed with the lower root forceps, 
Fig. 58. With only one root remaining in the socket the 
elevator as shown in Fig. 68 may be inserted in the empty 
socket and the root pried from its seat. 

The Second Molar 

Two roots, the same in the first molar, but not so diverg- 
ing. Consult Fig. 14, Chapter V. The same forceps used 

Fig. 70. — The extraction of the lower left second molar. 

and the same procedure in the extracting as the first molar; 
using an in-and-out motion, and again being careful to have 
the beaks well down in the bifurcation of the roots. Figs. 
69 and 70. 



The Third Molar 
(Wisdom Tooth) 

This tooth is the most difficult of all to extract because 
of its varying number of roots and its frequent malposition. 

Take a position as shown in Fig. 61 or 62, right or left, 
select a forcep with a short thick beak or the lower root 
forceps, Fig. 58. Forceps shown in Fig. 69 can also be 

Fig. 71. — The extraction of lower third molars, wisdom teeth. 

used to good advantage, except that there is a possibility 
of the tooth slipping out of the beaks into the throat. 

Place the inner beak over the inside of the tooth and 
guided by the fingers of the left hand, the outer end is 
brought to place, Fig. 71. 

The large thickness of bone on the outside of this tooth 
renders the outward motion useless. Turn the tooth di- 
rectly inward, keeping a good pressure on the forceps. 



This is just the opposite to the process necessary in the 
upper third molar. 

These teeth are malposed, at times to such an extent 
that without an operation which first aid in extracting 
would justify, their extraction is impossible. Impactions 
often occur such as is shown in radiograph Fig. 72, and 
Fig. 73- 

In Fig. 73 the tooth was erupting directly toward the 
outside. An inexperienced operator had failed in extrac- 
tion of the second molar. 

Fig. 72. Fig. 73. 

Fig. 72. — Impacted third molar. Radiograph. — (Author's practice.) 
Fig. 73. — Impacted third molar, with fractured remains of lower 
second molar from faulty extraction by inexperienced operator. Radio- 
graph. — (Author's practice.) 

When impactions occur such as would necessitate an 
oral operation, the first aid or emergency might justify 
the extraction of the second molar, when in majority of 
cases the trouble will be ended. 

The use of elevators, as shown in Fig. 68, may be very 
advantageous with these teeth. 

An Improvised Dental Chair 

In the ordinary medical office, hospital or in the field, 
the question of a proper dental chair arises. 



Figs. 74, 75 and 76 show the patient sealed in a com- 
mon chair and the back of another resting against this, 
the left foot of the operator on the second chair, a head 
rest is made by the knee. Excellent results and control 
of the patient may be had in this manner. 

The patient may push back and if he does this, the head 

Fig. 74. — Position of patient and operator in improvised Dental Chair: 
Two common chairs placed back to back, patient's head on operator's 
knee. Extraction of upper teeth. 

will force the operator's knee down and press down on the 
chair at the back. 

The head may be placed on any point of the operator's 
thigh to give a good view of the teeth to be extracted on 
"either side of the mouth. 

For the lower, Fig. 75, the head will be rested in the 
thigh and against the body of the operator. 



Fig. 75. — Improvised chair for extraction of the lower teeth, showing 
head resting on thigh and against body of operator. 


Fig. 76. — Extraction of upper teeth, left side. Same improvised chair. 


Pain after Extractions 

Pain after extractions may be a result of injury to the 
peridental membrane or to the alveolar process; spreading 
or compressing its plates, or to the gum tissue. 

The mouth being full of foul, septic matter, infection 
may later occur with resultant pain. 

The mouth as stated before, should be syringed out 
with a good antiseptic wash and the instruments be abso- 
lutely sterile, then painting the parts with tincture of 
iodine will be considered a sufficient precaution. 

Infection of sockets in many cases following the extrac- 
tion of one or a number of teeth is unnecessary. If the 
proper precautions are taken it will occur only in a very 
small percentage of cases. 

A record of five months of the writer's practice shows 
1,161 teeth (including many badly necrosed roots) ex- 
tracted with a result of four cases of infected sockets. 

After the removal of the tooth and the compression of 
the alveolar process, the sockets will be washed out with 
a hot solution. No cotton or medicine of any kind should 
be placed in them. 

If the gums are lacerated and the wound is gaping open, 
the cut or hanging tissue should be removed, with a small 
pair of curved scissors. Any points or jagged portions of 
the alveolar process should be broken down and smoothed 
over, with an elevator or a pair of forceps. Then paint' 
this part with tincture of iodine. 



In case of pain, after this treatment, make a paste of 
iodoform, orthoform and campho-phenique and saturate 
a strip of gauze, fold this into the socket, leaving it for 
twenty-four hours. 

A case dismissed may present in three or four days, 
with pain and infection in the socket. Wash out the 
mouth with a hot antiseptic and with a pair of tweezers 
and sterile cotton remove all the clot in the socket and 
flush out with a hot solution. 

The writer paints this with a very small pledget of 
cotton saturated in tincture of iodine, and applies the 
above paste. The tincture of iodine does no special good 
in this case, where the paste is to be applied, except 
possibly to reduce the pain while inserting the gauze. 

In nearly all cases of pain and infection, this paste will 
prove very efficient, the iodoform being antiseptic and the 
orthoform, a magic specific 1 for painful wounds, being a 
local anaesthetic, while the campho-phenique serves as a 
menstruum in mixing and appears to lessen the odor of 
the iodoform. 

Hemorrhages after Extractions 

Post-extraction hemorrhages may be very severe, even 
in the absence of hemophilia. These cases are not rare 
out are liable to be found at any time and must be dealt 
/nth wisely and promptly. All patients should be ques- 
ioned as to liability of hemorrhage, or if " bleeders" (the 
ommon name for hemophiliacs) are in the family. 

The death of a United States Senator, in recent years, 
^as caused by hemorrhage from the extraction of a tooth 
nd all known methods of treatment in this case were 

1 Buckley. 


Hemorrhage from a socket may be capillary or arterial, 
and unless the patient is of a hemorrhagic diathesis, little 
difficulty will be experienced in stopping the bleeding. 

Slight bleeding will yield sometimes to the holding of 
ice water over the socket. If no ice can be had a very 
hot solution will serve, used as hot as the patient can 
stand it. 

The use of persulphate of iron should not be restored 
to until all other remedies fail. 

If the cold or hot water does not stop the flow, the paste 
of iodoform, orthoform and campho-phenique on a folded 
piece of gauze, packed tightly in the socket will answer 
in most cases. A gauze pack of tannic acid in glycerine 
will serve also, forced to the bottom of the socket. These 
packs will be observed daily and left until there is no 
danger of recurrence. 

In hemophilia, the use of tampons and mechanical appli- 
ances will be necessary. The writer recommends the in- 
sertion of a gauze strip, longer than will be necessary, 
saturated with the paste of glycerite of tannin, folded 
upon itself to the bottom of the socket, when the gauze 
is flush with the gums, cut off the excess, fit a piece of 
cork over the socket, letting it extend down into the open- 
ing and trim it to the height of the teeth. Pressure is 
then made on this by a figure-of-eight ligature around the 
two teeth adjoining the socket, which serves to hold it 
in position. This cork may be held in place also, by the 
use of the Barton bandage, the former is preferable, when 
the teeth are present for attachment of the ligatures. 

In extreme cases, the tooth antiseptically treated may 
be replaced in the socket. 

The internal treatment should be conducted by the 
surgeon who will administer drugs which increase the 
coagulability of the blood. Those most commonly used 


are calcium chloride and calcium Lactate, 3 lo grains or 

0.2- to 0.6-gm. doses. 


Patients may faint in the operations on the teeth or 
even before, from the sight of the instruments or from 

The condition is the result of the passing of the blood 
from the head, especially the brain, which becomes anemic. 
It is generally merely a physical problem to lower the 
head and let the blood run back. A patient who turns 
pale and blanches may have his head lowered between his 
knees for a few moments, which will revive him. 

Dashing cold water in the face or the odor of ammonia 
will aid. In case these methods fail, from 10 to 20 drops 
of aromatic spirits of ammonia in water may be given, 
this being a cardiac and respiratory stimulant. 

In extreme cases a pearl of amyl nitrite may be broken 
in a handkerchief and held close to the patient's nose. 



This chapter is intended for Surgeons and Dental Sur- 
geons only. 

The operations and care of the above conditions must 
be considered under emergency treatment, although not 
strictly first aid. 

The surgeon or dental surgeon where the diagnosis of 
the condition is determined, cannot fail to see the necessity 
for emergency treatment. The methods of operation and 
treatment here described have given the writer and others 
such results that they are highly recommended. 

Diseases of the maxillary sinus are much more common 
than is supposed " they are common among the lower class 
of society, or people who neglect their teeth." 1 There 
are various diseased conditions found affecting the sinus, 
among which are suppurative inflammation of purulent 
empyema, mucous engorgement, syphilitic ulceration, ne- 
crosis of the bony walls, tumors and dentigerous cysts, 
containing unerupted teeth, deciduous permanent or 

This chapter will consider only the suppurative inflam- 
mation or purulent empyema, which has for its etiology, 
local conditions and diseases of the teeth, injurious catar- 
rhal affections, foreign bodies, present in the cavity and 
dentigerous cysts. 

All of the diseases of the teeth that have been taken 
up in this book which are located in the root canals, are 
etiological factors, especially those with putrescent pulps 

1 Marshall. 



and acute and chronic abscesses. The roots of the su- 
perior teeth, as previously shown, the cuspids, bicuspids 
and molars, are separated from the cavity by a thin floor 
of bone. In the formation of abscesses, this tissue is 
easily destroyed and the drain of the pus is directly into 
the sinus. 

Injuries, which fracture the bones of the face are prone 
to result in infection of the sinus, especially if the wound 
communicates with the mouth and gives access to the oral 
fluids. Other injuries spoken of as causes of empyema 
are the fracture of the process and the removal of portions 
of the floor in extraction of the teeth. 

Among common causes are the catarrhal affections of 
the nasal tract resulting in the inflammation of its mem- 
brane which is continuous with the membrane lining the 
maxillary sinus. 

Another cause is the presence of foreign bodies in the 
sinus, and in this class of causes dentigerous cysts are 
first to be considered. Nature tries to expel the teeth 
forcibly and they become sources of irritation and result 
in severe cases of pus formation. Other foreign bodies 
such as dental material, root-fillings, etc., may be forced 
through the root into this cavity. Insects may be taken 
in through the nose and find their way into this sinus. 

The symptoms of suppuration of the sinus are pain, 
dull and deep-seated, which later becomes intense and 
extends over the whole side of the head and face. The 
walls of the Antrum of Highmore become thin and Mar- 
shall states that under pressure they give forth a crack- 
ling sound like that of the crushing of an egg shell. 

The orbit forming the roof of the sinus, suppuration 
exerts its pressure on this and at times forces the eyeball 
to a marked protrusion and causes paralysis of the optic 
nerve from this force. 


If the discharge of pus is directed into the nose, the odor 
of the breath is very offensive. The condition is clearly 
one demanding prompt and decisive action. 

The diagnosis is at times somewhat difficult. Theuse 
of a light shadowing through the sinus, the soreness, pain 
and swelling on the side of the face affected. In unilateral 
or both, if bi-lateral, the presence of pus escaping through 
the nose, when the head is held down and quickly thrown 
back and to the opposite side, the soreness of the teeth, 
the crepitus of the thinner part and the X-ray for foreign 
bodies are the means of diagnosis. The radiograph is the 
most satisfactory method of locating foreign bodies and 
determining the condition. 


In every disease, the removal of the cause is the first 
thing to be considered, so with the maxillary sinus affec- 
tions, but when the cavity is full of pus, it demands pri- 
marily, opening and drainage. 

A local anaesthetic or Nitrous Oxide and Oxygen or 
other general anaesthetic may be used. A 2 per cent, 
solution of eucaine or cocaine as a local anaesthetic is 
used with success, but novocaine is preferable to either 
of these and all other local anaesthetics. 

There are many methods of operating for this condition. 
Some operators extract the first molar or bicuspid tooth 
and make an entrance into the sinus, through the sockets 
of these with a trephine or engine drill. Marshall has 
devised an excellent trocar and canula for this operation 
and in this method of entrance it is very desirable. 

The writer recommends the method shown in Fig. 77. 
A root reamer bur/is selected for the dental engine. The 
distance determined that the drill should enter and a gutta- 



percha ball placed on the burr at this point, to prevent 
its slipping and puncturing the floor of the orbit. Make 
an incision well up over the side of the roots of the second 
bicuspid and first molar teeth; insert the drill between 
the roots. An opening as large as an ordinary lead pen- 
cil will suffice for suppuration, unless the removal of 
foreign matter requires a larger one. This is the best 

Fig. 77. — Empyema of the Antrum of Highmore, position showing 
method of opening with drill, with gutta-percha guard, between the 
roots of the second bicuspid and the buccal root of the first molar. 

place in the mouth to open into the antrum because it 
is a dependent portion and is better than going through 
a tooth socket because the food and oral secretions do 
not have access; since the cheek covers the wound. 
Where the dental engine is not available or desired, the 
chisel and hammer may be nicely used, the opening being 
made large enough to admit exploration with the fingers 
if desired to remove foreign bodies. 


E. J. Craig of Kansas City has a method of making a 
drain as follows: Take a silver wire, 20 gauge, wind it 
over a handle slightly smaller than the opening, to make a 
close coil about 1 inch in length; this may be bent in 
any direction. Insert it in the opening and keep it there 
for one or two days. Flatten the outer end so that it will 
not irritate the buccal tissue. This drain will not work 
through into the antrum as many drains are liable to do 
and it affords entrance for the syringe tip. The opening 
will not close after its removal if left for two or three days. 

The cavity should be syringed out with a normal salt 
solution, ioo° temperature from a Moffat syringe, or a 
fountain syringe, with a glass nozzle made to fit the case, 
the bag containing the water held not higher than the 
patient's head, in the first few sittings. 

The use of 10 per cent, argyrol solution is an excellent 
remedy after the drain has been perfected through the 
nose. Harlan recommends in chronic cases, after irrigat- 
ing as long as deemed necessary, flooding the cavity with 
a 2 per cent, silver nitrate solution, which makes a pro- 
found impression on the tissues and further treatment is 

In chronic cases which have large openings, from an 
operation to remove foreign matter, the bismuth paste 
given in a previous chapter is injected by some operators 
with great success. The cavity after operation is packed 
with this paste on gauze, continuing the washing with 
the warm saline solution for time desired. An operation 
for a typical case of dentigerous cyst was performed at 
a convention of the New York State Dental Society, by 
Dr. Henry Sage Dunning, of New York, Dr. Dunning has 
very kindly furnished the following description of same 
with use of plates. 

"Patient, young Swede, seventeen years old, came to 



clinic complaining of swollen face, upper right side and 
slight pain. Patient said that the face had been swollen 
for about eight to ten months. Sometimes swelling would 
increase and become hard and then would get smaller or 
go down and patient thinks he would at this time notice a 
discharge in the mouth. 

Examination. — Face, swelling of face marked, extending 
from infraorbital region to alveolar process and from ala 
of nose to zygomatic arch, the entire wall of antrum was 
ballooned anteriorly about 1/ 2 to 3/4 of an inch. Bony wall 




end of 


Fig. 78. — Dentigerous cyst in the maxillary sinus. Radiograph. 
— (Dr. Dunning' s practice.) Case cited. 

of antrum greatly thinned out and a distinct egg-shell 
crackle noted. Somewhat tender, above area somewhat 
red and slightly warmer than on other side. Fig. 78. 

Mouth, central lateral, first bicuspid, second bicuspid, 
first and second molar in position, and in good condition. 
Third molar erupting, canine missing, and space of 1/2 
inch between lateral and first bicuspid. Marked swelling 
over alveolar ridge, extending from canine fossae to second 
molar region. This swelling was oval in shape and was 
about the size of a pigeon egg. External plate was thin 


and egg-shell crackle noted as on face. Small sinus noticed 
just over the lateral and probe could be passed along neck 
of this tooth into its alveolus, up into large cavity for a 
distance of about i inch. X-ray showed non-erupted 
permanent canine just over lateral root, and above this 
there was shown another tooth, which looked like a super- 
numerary tooth. Large cavity shown by X-ray to involve 
antrum, but unable to tell by film to what extent. Roots 
of the two bicuspids somewhat absorbed and extending 
into the cyst cavity. 

Diagnosis. — A true dentigerous cyst, containing two 
teeth. Nose examined, negative; ear examined, negative. 

Operation performed before the members of the New 
York State Dental Convention at Albany, New York. 
Patient given 1/6 grain morphine by hypodermic to quiet 
him and to relieve from post-operative pain. Cyst area 
painted with 1/2 strength iodine. One per cent, novo- 
caine injected into swelling of alveolar border, deeply 
into periosteum and bone. An incision was then made 
along swelling, extending from lateral to second molar. 
Soft tissues laid back and bone exposed. Anterior wall 
of antrum found to be very thin; with chisel and mallet 
broke through thin external alveolar plate and found large 
cavity full of thick yellow pus, containing white flakes. 
Enlarged cavity quickly and entire wall of antrum found 
to be thin, soft and necrotic in places. . With rongeur 
forceps removed large area of diseased anterior wall and 
made opening into the antrum, that would allow passage 
of ends of four fingers of hand. Excavated about 1 1/4 
ounces of thick pus, irrigated the cavity with warm saline 
solution and for the first time obtained good view of the 
cavity. Cavity extended from floor to alveolar ridge of 
orbit, from second molar to lateral and upward to floor 
of nose. Cavity lined with smooth thin membrane or 


sac, which was partly removed by the operator. Cavity 
curetted and two teeth, a temporary canine and perma- 
nent canine dislodged from bony wall. Rough edges of 
thin bone surrounding opening into cavity smoothed off 
and cavity packed with bismuth paste and gauze. This 
cyst cavity was found to connect directly with the nose. 
The membrane lining the bone cavity seemed to wall off 
nose at middle meatus, the natural communication of the 

Cyst cavity 
filled with 

Fig. 79. — After operation-cavity filled with bismuth paste. 

nose and antrum. A puncture through the nose, into the 
cavity was performed to establish better drainage. 

Treatment. — Cavity has been packed with bismuth paste 
gauze and irrigated with warm saline solution about three 
times a week for the last three months. Opening has 
closed in considerable but cyst cavity about the same size. 
Tissues are clean and healthy. 


Prognosis. — Opening into cyst cavity and antrum will 
continue to fill in, but will never completely close. No 
danger of recurrence, as lining of membrane of cyst has 
been removed and source of irritation, the teeth, has been 
removed. Fig. 79. 


Abbott: " Principles of Bacteriology. " 

Allen: " Vaccine Therapy and Opsonic Treatment. " 

" American Text-book of Operative Dentistry." 

Black: " Dental Anatomy." 

Bodecker: "Anatomy and Pathology of the Teeth." 

Broomell: "Anatomy and Histology of the Mouth and Teeth." 

Buckley: "Modern Dental Materia Medica, Pharmacology and 

Burchard: "Dental Pathology, Therapeutics and Pharmacology." 
Burchard and Inglis : "Dental Pathology and Therapeutics." 
Burr, Aaron: "Dental Cosmos." 
Cryer: "Internal Anatomy of the Face." 
Da Costa: "Gray's Anatomy." 
"Dental Cosmos." 
Gorgas: "Dental Medicine." 
Harlan: "Lectures." 
Hunter: "Oral Sepsis." 
"Items of Interest." 
Jackson: "Orthodontia." 

Johnson: "Principles and Practice of Filling Teeth." 
Keyes: "Syphilis." 
Longmore: "Gunshot Wounds." 
Marshall: "Injuries and Surgical Diseases of the Face, Mouth 

and Jaws." 
Miller: "Micro-organisms of the Human Mouth." 
Ottolengui: "Methods of Filling Teeth." 
Prinz: "Dental Materia Medica and Therapeutics." 
Stimson: "Fractures and Dislocations." 
Talbot: "Interstitial Gingivitis." 
Tomes: "Dental Surgery." 
Wallis: "Atlas of Dental Extractions." 
Zeigler: "Pathology." 



Abrasion, mechanical, 43 
Abscess, acute alveolar, 46, 49 
treatment, 65-67 
abortive, 65, 66 
drainage, 66, 67 
general, 66 
lancing, 66 
local, 65 
chronic alveolar, 49 

antrum of Highmore, 50 
cause and classification, 49 
diagnosis, 51 
situation, 50 
chronic, without fistula, cause, 49 
perforated roots, 68 
treatment, 67 
chronic, with fistula, extraction, 
irrigation, 70 
treatment, 69 
Absence of proper teeth for masti- 
cation, 4 
Absorption, vaccine and bacteria, 3 
Alimentary tract, 2 
Alveolar process, 40, 41 
Alveoli, necrosed, 5 
Anatomy, dental, 34 
Anemia, mouth organisms, 3 
Antiseptic mouth wash, value of, 5 
Antrum of Highmore, diseases of, 
cause and symptoms of, 

diagnosis, 140 
drainage, 142 
history of case of dentigerous 

cyst, 142 
diagnosis, 144 

Antrum, history in examination, 

operation, 144 
prognosis, 146 
treatment, 145 
method of entrance, 141 

purulent empyema of, 138 
treatment, 140 
Articular rheumatism, 3 


Bacillus pyocyaneus, 1 

Bacteria, presence of in the mouth, 

absorption of, 2 
Brushing of teeth properly, 12 

Calco spherites, 43 
Calculus, serumal, 7-15 

salivary, 8-15 

technique of removal, 9-15 
Campho-phenique, 54 

-iodoform-orthorform paste for 
painful sockets, 5 
Canker "sore mouth," cause, 18 

description, 18 

treatment, 191 
Carbolic acid, 54 
Cause of gastric disorders, 4 
Cementosis, 74 
Cementum, 38 
Chancre vs herpes, 30, 31 
Chisel, use of, 58 

Chloroform, aconite and iodine, 64 
Chronic alveolar abscess (see ab- 
scesses), 49 




Cicatricial tissue of abscesses, 50 
Cloves, oil of, 54 
Cold sores (herpes labialis), 17 
Conditions of the mouth, crowns, 
ill fitting dentures, 1 

necrosed roots, 1 

pathogenic bacteria, 1 

tartar, 1 
Cotton pledgets, use of, 50-56 

rolls, use of, 54, 55, 57, 86, 87 
Counter irritant, 64 
Cresol and formaldehyde, 63 


Defective fillings, 42 
Dental anatomy, 34 
deciduous teeth, 34 
eruption of, 35 
extraction, 36 
pain, 42 
~ Pulp, 39 

exposure of, 42 
Dentine, 37, 38 
exposed, 73 

secondary, cause of neuralgia, 73 
Deposits, classification of, 6, 7 
deposition of, 7, 9 
location, 7 

technique of removal, 9-15 
Differential diagnosis of chancre 

and herpes, 30, 31 
Dislocation of lower jaw, anatomy, 
percentage, 101 
symptoms, 103 
treatment, 103 
Dobell's solution, 4, 53 
Dressing pliers, use of, 52 


Enamel, definition of, 37 
Eruption of teeth, 36 
Eruptions, syphilitic, 27, 30, 31 

Excavators, use of 52, 55, 56 
Explorer, use of, 52-55 
Exposed dentine, 73 
Exposure of the pulp, 42 
diagnosis, 43, 44 
treatment, 52 
Extractions, accidents, 104 
choice of forceps, 108, 109 
handles, 109 
material, 109 
shape and size, 109 
sterilization, 109 
deciduous teeth, 36, 105 
extraction of the lower teeth, 
central and lateral incisor 
and canine, 120-122 
first and second bicuspids, 

122, 123, 124 
first molar, 125-128 
second molar, 128 
third molar, 129, 130 
of the upper teeth, central 
incisor, no, in 
cuspid or canine, 114, 115 
lateral incisor, 112 
first and second bicuspids, 
116, 117 
molar roots, 118 
molars, 117 
the third molar, 118, 119 
failures, 105 
improvised dental chair, 130- 

infection, fo6 

lancing, 107 

position of patient, 106 

post-operative conditions, 134 

fainting, 137 

hemorrhage after extraction, 

treatment, 136, 137 
pain after extraction, 134, 135 
preparation, 108 
procedure of extracting, position 
of patient, 109, no 




Facial neuralgia, 73 

Fainting, 137 

Fever blisters (herpes labialis), 17 

Fillings, defective, 42 

removal of, 59 
Formaldehyde, 63 
Fracture of teeth, 43 
Fractures, cause, 88 
classification, 88 
treatment, 89 

inferior maxilla, 88-90 

cases cited, 90, 91 

classification, 90 

gunshot, 90 

incomplete and com- 
pound, 90 
bandaging, 98 
delayed union, treatment of, 

edentulous jaws, 92 
frequency of, 91 
traction of fragments, 99 
treatment, 92 
wax molds, 93 
wiring method, 95-98 

I Eerpes, definition, 1 7 
differentia] diagnosis with chan 

ere, 30 
treatment, [8 
Hyperemia, relative to dento- 
alveolar abscess, 47 


111 fitting dentures, 1 

favorable for growth of germs, 1 
stomatitis from, 16 
Impacted teeth, 74 
Incisor tooth, implantation and 

structure, 37 
Infection from syphilis, 27-29 
immediate prevention from acci- 
dental infection, 30 
Inflammation of the dental pulp, 42 
Injuries of the mucous membrane, 
cause, 19, 20 
treatment, 20 
Instruments, 108 

Iodine, tincture of, for infected 
sockets, 4 

Gingivitis, definition, 21 
marginal, cause, 21 
location, 21 
treatment, 23, 24 
Growth of disease producing germs 

in mouth, 1 
Gum boil, 50 
Gums, 50 

inflammation of, treatment, 5 


Hemorrhage after extracting, 135 
Herpes labialis (fever blisters), 17 
confusion with syphilitic erup- 
tion, 27 

Jaws, anatomy of, 88 
fracture of, 88-100 


Lancing, 66 
abscesses, 66 

in extraction of roots, 107 
Local cause of pyorrhea alveolaris, 


Marginal gingivitis, 21 
mouth wash for, 24 
Maxillary sinus (see Antrum of 

Highmore), 138 
Mechanical abrasion, 43, 59, 60 



Mirror, mouth, use of, 52, 54, 55 
Mouth organisms, diseases attrib- 
uted to, 3 
Mucous membrane, injuries of, 
cause, 19, 20 


Necrosed roots, source of infec- 
tion, 4 
Neuralgia (nerve pain), cause, 72, 

description, 72 
facial neuralgia, cementosis, 74 

exposed dentine, 73 

impacted teeth, 74 

pericementitis, 74 

pulpitis, 73 

pulp nodules, 73 

treatment, 75-77 


Oil of cloves, 5 

Oral cavity, treatment and steril- 
ization, 4 1 

Pain, dental, 42 

post-operative, 134 
Pathogenic germs, 2 
Pericementitis, 74 

acute septic (dento-alveolar ab- 
scess), cause, 46, 47 
diagnosis, 48 
pressure of blood, 48 
process of, 47 
cause, 46 
definition, 46 

non-septic, counter-irritation, 64 
diagnosis, 46 
treatment, 64 
Pericementum, 38, 39 
Post-operative conditions, 134 

Primary syphilis (see syphilis), 26 
Probe, use of, 51 

Ptyalism (salivation), cause and 
appearance, 32 
treatment, 32, 33 
Pulp, exposure of, 42-44 
nodules, 73 
stones, 43 
Pulpitis, 42 
treatment, 5 

congested pulp, 57 
mechanical abrasion, 60 
neuralgia, 73 
proper drugs to use, 54 
removal of filling, 59 
sterilization, 52, 53 
Pus, abscesses, 46-50 
Putrescent pulp, cause, 45 
diagnosis, 45 
treatment, 61-63 

cresol and formaldehyde, 63 
sealing of treatment, 63 
three important factors, 61 
use of broaches, 62 
of cotton rolls, 61 
Pyorrhea alveolaris, absorption of 
bacteria, 2 
acute septic pericementitis, 47 
classification of features, 78 
dento-alveolar abscess, 47 
difference in etiology, 79 

local and general etiology 
described, 79 
process of disease, 80 
diagnosis, 83 
extraction of teeth, 84 
general and constitutional 

causes, 81 
heredity, 86 

instrumentation and treat- 
ment, 84-87 


Removal of deposits, 9-15 



Salivary deposits, 6, 8, 9 
Salivation (ptyalism), 32 
Sandarac varnish, 56 
Secondary dentine, 43 
Serumal deposits, 6, 7, 8 
Silver nitrate, 60 
Smokers' sore mouth, 20 
Sockets, pus ridden, 4 

painful, 5 
Sore mouth (canker), 18 
Staphylococcus pyogenes albus, 1 
aures, 1 
citrus, 1 
Sterilization of instruments, 52 
Stomatitis, causes, 16 

definition and classification, 16 
treatment, 17 
Streptococcus pyogenes, 1 
Syphilis in the mouth, first aid 
treatment, 25-30 
immediate prevention of acci- 
dental infection, 30 
primary syphilis, infection from, 
secondary, diagnosis, 27, 28 
nature of manifestations, 27 
sterilization of instruments, 25 
tertiary, infection, 29 

nature of manifestations, 29 

Tartar, 6 

Teeth, correct method of brushing, 

deciduous, 34-30 
fractures of, 43 
impacted, 50 
Tincture of iodine, aconite and 

chloroform, 64 
Tonsilitis, mouth infection, 2 
Toothache, 42 
Tract, abscess, 50, 47, 48 

Varnish, sandarac, dressing, 56 
Vaseline, use of as dressing, 56 


Wash, mouth, 3-5, 19, 24, 33 

X-ray in fracture of maxilla, 95 
in neuralgia, 74, 75 
in treatment of chronic ab- 
scesses, 5